Preparing for the FFICM (final) examination – an examiner’s view

FFICM is a ‘high stakes’ exam taken by ICM trainees, and is mandatory before entry it stage 3 training. This article aims to give some tips and pointers to trainees who are preparing for this exam, written by an experienced FFICM examiner.  

Use the current curriculum to guide your preparation. The exam is set at the end of stage 2 training, matched closely to the FICM curriculum. Hence it can include questions on any area of the curriculum, including what was formerly called ‘complementary specialties’ (general medicine for trainees with an anaesthesia background and anaesthesia for those from medicine) and all the sub-specialities of PICU, neuroICM and cardiac ICU. Intensivists need to be able to deal with the critically ill from all specialties, and the curriculum (and hence the exam) reflects this. Relevant basic science is also included in the curriculum so is regularly tested in the exam. 

After exam sitting of the exam, the chair of exams writes a report which details areas, as noted by examiners, where a number of candidates have scored badly.  These reports (on FICM web site) can be useful for trainees preparing for future exams. 

The Multiple choice examination 

This is moving (at the request of GMC) to become all single best answer questions. These questions have a stem and a number of responses, of which one is the best answer. There may be elements within the distractors which are correct, but one answer is superior. Some of these questions will test basic sciences, others will be clinical. These test both knowledge and also understanding and judgement. A good knowledge base is required, as well as practice at this type of question (which may be less familiar to candidates). It is important to read the stem accurately in order not to be distracted by plausible but incorrect answers.       

The OSCE examination  

This has 13 7-minute stations (including a test station), and usually includes stations on ecg interpretation, radiology, equipment, communication and simulation as well as clinical stations. A short statement outside the cubicle will guide the candidate as to the type of station, and may also have relevant clinical information.  The instructions, questions and marking schedules are fixed, and the pass mark for each station has been predetermined. 

The OSCE tests knowledge and skills, including decision making, prioritisation as well as communication and some practical skills. 

Ecg and radiology stations: A ‘report’ on an investigation will be expected to demonstrate a systematic approach, and so for an ecg would be expected to include comments on patient details and date (or absence of these), calibration as well as rate, rhythm, axis, P waves, PR interval, QRS morphology, QT interval, ST segment, T waves, any other findings, location of abnormalities and interpretation of findings.  

For a chest radiograph, a report would be expected to include comments on the patient details  and date (or absence of these), orientation, position/ side description, rotation, adequacy of  the study  as well as  comments on the airway, mediastinum, cardiovascular structures, lungs including hilar, bones, diaphragm, upper abdomen, any pathology or iatrogenic structures.  

A candidate may not be required to give a full report for all images- in this case the examiner will ask for ‘important findings’ (and in the interests of time will interrupt the candidate if they start a systematic report).  

Trainees may find sources designed for general medicine trainees or medicine exams helpful in their preparation for these stations, as well as attending teaching sessions designed for medical speciality trainees.  

Communication: This station involves communication with a mock patient, relative or healthcare professional, played by an actor who has been briefed as to what to say and what questions to ask. The instructions outside the station, and the actor’s responses, will guide the expected content of the communication.  The examiner does not interact in this station. Marks are awarded both for what is said, and the communication style (including use of lay terms, avoidance of jargon, body language etc). The actor should be treated as their role suggests eg a ‘relative’ would not be expected to understand medical terms (which should therefore be avoided or explained), and the level of detail expected is that which is appropriate for the simulated situation given.  Trainees will find that observed practice at this in the clinical environment with feedback from a consultant is useful in preparation for this station.   

Simulation: The simulation station includes a high fidelity mannequin, with examiner(s) and/or actors in the role of ‘helpers’. The role  of the ‘helper’ eg ED core trainee, anaesthetic nurse etc will be made clear to the candidate, either at the start of the simulation station or as the helper arrives. Helpers can be assumed to be competent in their role. There may also be artefacts (eg radiographs) introduced into the simulation scenario, either at a specific time point or when asked for by the candidate. Candidates are not required to be ‘bare below the elbows’. 

The simulation scenarios may include resuscitation from cardiac arrest, or may be about the management of a patient who has been referred to, or is in critical care. Note that the level of performance expected is that of end of stage 2 ICM training (which is higher than that expected of candidates on life support or some other courses, and of candidates in core exams). Knowledge, data interpretation, integration of data within a rapidly evolving clinical scenario, situational awareness, integration of multiple changing inputs and conflicting priorities, decision–making, team working and leadership and communication can all be tested in this station, and the mark sheet reflects this.  Candidates should behave as if in clinical practice, and may find it useful to ‘think out loud’ during the simulation, to demonstrate some of these features. The simulation may be stopped by the examiner so that questions can be asked, in order to assess decision making etc.  

In preparing for this station, a wide range of clinical experience is useful, as well as practice simulations with feedback, on courses or in hospitals, as long as the expected level of performance is appropriate.    

Equipment station:  This will involve an item of equipment (or a photo) with questions on its use, or the candidate may be asked to demonstrate an aspect of its use.  

Clinical station: These include a short summary of a clinical situation outside the station, with a number of artefacts (eg blood results, radiographs) to be interpreted and questions to be answered. The clinical summary will also be available inside the station, so it is not necessary to ‘memorise’ it, however do read it all in detail as it contains useful information for that station.  Normal values for blood results etc will be given.  

Candidates should integrate all the available information, eg a question about the ‘most likely diagnosis’ which has already included clinical information, then arterial gases, then blood results, then an xray, may have a different correct answer to ‘the most likely diagnosis’ of the xray findings alone.   

General tips for OSCE questions.  

Try to answer exactly the question being asked; in the question on the ‘causes of X’ there will be no marks for listing treatment options. 

‘Interpretation of data’ requires explanation- not just a description of what the data shows.  

Marks cannot be scored for previous questions within a station once the examiner has moved on, so candidate should not ‘dwell’ on previous questions, but try to focus on what is being asked. 

Examiners do not ‘hint’ at answers. If a candidate does not know the correct answer, they will pause, and then move on.  So if the examiner is silent and does not move on immediately after your answer, try to expand. This is unlike the approach some candidates may have experienced in ‘viva practice’, where an incomplete answer is followed by broader and broader hints to guide the candidate’s thinking. In the exam, the only prompts by the examiner will be those written into the question (to ensure the exam is delivered equally to all). The set pass mark for each question takes this into account.  

Marks will not be scored if a ‘scatter-gun’ approach is used. Eg if a question on ‘the most likely diagnosis’ is asked, only the first answer will be taken (unless a candidate corrects him/herself clearly).   

A candidate can ask the examiner to repeat the question, if required.  

Examiners do not give feedback as to whether an answer is correct or not, except where the question requires this to avoid ‘double-jeopardy’. Again this may be different to the style of teachers giving exam practice. 

Examiners interrupt, in order to ask sufficient questions to maximise the marks for each candidate. This occurs particularly if a candidate has scored the mark(s) available for a question so cannot gain any more marks on that question (however much they know!) and needs to move on.   

Examiners move on as soon as a question has been answered; this is to maximise the number of questions asked, and so improve the candidates overall mark. This can feel like fast ‘pressured’ pace, but it is done to maximise candidate marks. 

Try to focus only on the current station. If a station seems to have gone badly, try to forget about it and move on. The ‘pass mark’ for each station varies (so more ‘difficult’ questions have a lower pass mark) and none require 100% to pass. Each station is weighted equally within the exam, so additional marks on one can compensate for a poorly answered station and here are no ‘killer stations’ which must be passed in order to pass the exam. Many successful candidates do not pass all stations. In addition, there is nothing to be done about a previous station, so to maximise marks, a candidate should try to focus only what is currently being asked.   

Some stations do not use up the whole 7 minutes, and a high mark can be gained with time to spare.  

The Structured oral exam 

This consists of 8 questions, asked in pairs (two examiners marking each question). The starting topic is listed on the wall outside the cubicle. Each question will have 5 sections, which may require answers with different levels of detail.   

Topics are drawn from the whole of the stage 1 and 2 curriculum (including relevant basic sciences). This examination tests both knowledge and also intellectual skills such as understanding, prioritisation, organisation of ideas, and answers are expected to be broader than in the OSCE.   

In the SOE examination, the candidate will do most of the talking and many of the questions require answers which include a lot of items; use of a suitable classification or framework to organise the answer can assist a candidate maximising their marks for these questions.      

Examiners may probe a candidate’s knowledge and understanding, more so than in the OSCE – this can feel challenging, however it is an important part of assessing the range and depth of understanding, and maximising the opportunity for marks. Candidates should expect to feel ‘stretched’ in some areas of questioning; but in fact the questions which initially appear to be more challenging to a lot of candidates are often not the ones which score low marks.  Using a suitable framework or classification to structure the answer can lead to remembering additional facts.  

Try not to dwell on a ‘bad’ question; it may not have been as bad as you think as the knowledge required for questions varies but is always lower than 100% (and there is nothing you can do about it after the event).  There are no ‘killer questions’ in the SOE, so additional marks on other questions can compensate if needed.    

Examiners will not give feedback on the answers given, whether correct or not.  This may feel strange to a candidate who has practised in a setting where feedback and ‘hints’ are given.   

There may be silence; if a candidate does not immediately answer, or stops talking before the answer is complete, examiners can give a candidate a short time to think before moving on. Marks are not being scored during the silence, but the candidate can use this time to organise their ideas etc. 

Examiners may interrupt a candidate in order to re-focus on the question being asked or to move them onto the next section, as marks are available in all sections. This happens particularly when a candidate has deviated from the question being asked, or has scored the marks available for that section. Both of these strategies aim to maximise the candidate’s chances of scoring marks.   

A wide range of experience, study of texts and journals (using the curriculum as a guide) and viva-practice from consultants can all be useful in preparing for this exam.   

A few practical tips 

Arrive in plenty of time; allow for unexpected transport delays etc. You may choose to bring a snack/drink for the gap between exams (water is provided).  

Get as much practice as possible, both on formal courses and from Consultants.  It may be useful to remind those giving practice that examiners do not prompt or give feedback during the exam. 

The breadth and depth of knowledge on a topic which is expected of a successful candidate varies, according to the topic.  Knowledge of those conditions which are commonly encountered or most important will be required in greater depth than those which are rarer or less important; however an ICM specialist can be required to treat the sickest patients of all the specialties, so a very wide breath of knowledge is also required. 

And if you fail repeatedly, ask for a guidance interview. At this an examiner will review your answer papers, and try to offer pointers to guide your further study. Each candidate can request one guidance interview, and then one is mandatory before the sixth attempt at a part of the exam.     

In summary, sufficient breadth and depth of knowledge and clinical experience (guided by the curriculum) with realistic practice at the examination types (with feedback) should give candidates the best possible chance at success.