Resources for Candidates

A group of subject-matter experts judge how difficult each item is in an exam. This produces a defined absolute ‘pass mark’ standard, based on the questions. The Angoff method is widely used in high-stakes exams such as OSCE and MCQs. 

The experts consider each item and how likely a borderline (or minimally competent) candidate is to answer each item correctly, and then allocate a probability of this borderline candidate answering correctly. A ‘borderline’ candidate is one who has completed the required training, has an average amount of knowledge and has done a reasonable amount of exam preparation, and who has a 50% chance of passing the exam (and 50% chance of failing).

Borderline regression is an examinee-referenced standard setting method, which uses a global score, based on the examiner’s judgement of each candidate’s performance during the exam. It is also a well-recognised widely used method of standard setting in high stakes exams.

A candidate is awarded marks for their answers to items within the question, then a ‘global score’ for overall performance in the question. Examiners agree the definition of the points of the global score in advance (e.g. score 1-5 with 3 as ‘borderline’). 

A graph is then plotted of marks against global scores and a line of regression is drawn. Where the regression line intersects ‘borderline’ indicates the pass mark for the exam.

The MCQ paper pass mark is set by the MCQ sub-group examiners. The Angoff method is applied to each question individually. These scores are then weighted, because ‘long’ single best answer questions are worth two marks compared to ‘short’ single best answer questions. The paper pass mark is the sum of the weighted individual question Angoff marks. 

Each OSCE question has a number of sub-questions, with a total of 20 marks available for each question and 12 questions per exam. The test question does not contribute to the candidate’s score. The Angoff process is carried out by the OSCE sub-group examiners, who apply the process separately to each mark within each question. The Angoff mark for a question is the sum of the Angoff scores for each mark within the question, and the pass mark for the OSCE exam is the sum of Angoff marks for the questions it contains. As each question has an individual Angoff mark, if more difficult questions were to be selected into an exam, then the pass mark for that exam will be lower.   

SOE questions are subjected to an Angoff process (undertaken by the SOE sup-group of examiners) in order to establish the question difficulty; this is to aid question selection but is not used to establish the pass mark.

Borderline regression is used to establish the pass mark for the SOE exam.  Each examiner awards a separate score for a candidate’s answers to the two questions in that station, then awards an overall global score for their performance in the station. The total score for a candidate in the exam is the sum of individual question scores. The pass mark for the exam is determined by borderline regression of the question scores against global scores for all candidates. 

Candidates are expected to be able to interpret a wide range of ECG abnormalities, as might be present in patients in or referred to a general critical care unit, as well as cardiac critical care and PICU.

When the examiner asks for a ‘report’ or ‘systematic report’, a full report is expected.
This should include

• Patient name/ date of birth/ number (or absence of these). NB. The actual name etc should be included, not a general statement about checking these.
• Date of investigation (or absence of this)
• Comment on paper speed and calibration
• Rhythm, rate (approximate rate is acceptable), axis
• Any abnormalities of PR interval, ST segment, QT interval 
• P wave, QRS, T waves – any abnormal features  
• Lead location of any abnormalities (e.g. Q waves or ST segment elevation) 
• Presence of ectopic beats or beats that are different to the others
• Presence of other abnormalities e.g. J waves, pacing spikes etc

Having described these features, the candidate should then interpret the important findings, i.e. conclude what these descriptive features mean. 

If the examiner asks for ‘abnormal findings’ then a full report is not required, just an identification of the specific abnormal findings.

If the examiner asks for ‘interpretation’ then a conclusion is required. For example, the abnormal findings of ST segment elevation in leads II, III and aVF leads to the conclusion of acute inferior myocardial infarction. Be as specific as is possible e.g. including ‘acute’ and ‘inferior’.

Candidates are expected to be able to interpret a wide range of relevant radiology investigations, as relevant to patients on or referred to critical care units (including PICU, cardiac ICU and Neuro ICU). These can include plain radiographs (e.g. chest, thoracic inlet, abdomen, neck, limb), CT (head, neck, thorax, abdomen, limbs, including reconstructions). 

Where MRI, interventional angiography or radioisotope images are used, these will be straightforward images only. Only one or two images from a series will be shown (e.g. CT scans) that have been selected to show the relevant anatomy or feature(s).

Single images or short videos of echocardiography or ultrasound may be included. These will be normal or straightforward abnormalities, such as those obtained by a FICE-accredited practitioner in a bedside study or similar (e.g. echo of ventricular function, filling status, valve abnormality, size of the heart, any kinetic or dyskentic segments, pericardial effusion with or without evidence of tamponade, ultrasound of abdomen chest vascular access).

If the examiner asks for a report or a systematic report of a chest x-ray, then the following should be included. Note a report will only be asked for when a complete examination is present in the exam (e.g. chest radiograph) and not when a single ‘image’ from an investigation that contains multiple images (e.g. CT) is used.

A report for a chest radiograph should include:

• Name, date of birth, number (or absence of these). NB. The actual name etc should be included, not a general statement about checking these.
• Date of image (or absence of this)
• Comments on other relevant available details e.g. mobile/antero-posterior (AP) projection etc.
• Adequacy of image, penetration, rotation
• Systematic review and comment of all areas including;
  • lung fields
  • trachea and airways
  • hilar
  • mediastinum and heart shadow
  • diaphragm, costophrenic angles
  • bones
  • areas below the diaphragm 
  • ‘hardware’ visible e.g. nasogastric tube and the position of the tip, surgical clips    
  • Anything else abnormal

If the examiner asks for ‘main abnormalities’, or ‘important findings’, a full report is not required, only an identification of what is abnormal on the image (or that the image has no abnormalities) or what is relevant to the clinical details of the question. 

High fidelity simulation using a mannequin is used to simulate clinical scenarios in the OSCE. For features which would be identified by examination of a patient, the mannequin should be examined as would be expected for a patient, and the examination findings (where appropriate) will be generated by the mannequin. Where it is not possible to simulate a finding, the examiner will supply the information.

The simulator used can generate:

• Airway obstruction
• Chest wall movement when breathing
• Breath sounds (normal and abnormal)
• Heart sounds
• Pulse (radial, carotid, femoral)
• Eye opening
• Pupil size
• Voice (examiner will provide this)

The following cannot be generated by the simulator - an examiner will provide details of these findings if asked:

• Temperature (core and peripheral)
• Cyanosis which develops during the scenario
• Any rash which appears during the scenario

The mannequin is connected to a monitor which can display observations such as heart rate and ecg, saturation, plethysmograph, blood pressure and arterial pressure trace, central venous pressure and waveform, capnography and other parameters. The monitor observations will change in real time during the station, as appropriate for the scenario.

Procedures

It is possible to intubate the trachea of the mannequin (which has the expected airway anatomy), insert a tracheostomy, perform bag-mask ventilation, cannulate veins, defibrillate, insert chest drain.

‘Helpers’

There will be one or more ‘helpers’ in the station as well as the examiner who is scoring the candidate’s performance. The ‘helper’ is played by another examiner. The ‘helper’ will have an identified role (eg Emergency Department registrar, ICU nurse eg) which will be made clear to the candidate either in the instructions outside the station or when the person is introduced.

The ‘helper’ will be able to carry out any task which a person in their role would be expected to do. Candidates can assume that any task delegated to a ‘helper’ will be done competently, however they will need direction as to what exactly a candidate wants them to do eg what parameters on a ventilator to set. If a task is delegated inappropriately, the helper will say that they cannot do that task eg if a candidate asks a ‘helper’ to obtain an arterial blood gas sample, they will either accept the task or say ‘I can’t do that’.

We do not expect candidates to be familiar with all models of equipment, so if any equipment is to be operated (eg defibrillator, ventilator, syringe pump etc) , the candidate should instruct the ‘helper’ in the scenario as to what is required (eg ‘change the respiratory rate on the ventilator to 16 breaths per minute’ ‘defibrillate  one shock of 200J’ ); the helper will then operate the equipment as directed.

Assessment

OSCE stations involving high fidelity simulation are used to assess a number of skills (mainly cognitive) and competencies, including:

• Knowledge of guidelines
• Problem solving
• Diagnostic reasoning
• Ability to prioritise 
• Situational awareness
• Decision making in complex scenarios
• Team working and team leading
• Data interpretation may be included
• Communication with patients, relatives and health care professionals

Of note, this is a much wider range of skills being assessed than ‘ability to know and run a protocol’. The expected level of performance is that of a trainee at the end of Stage 2 ICM training, and scenarios are chosen from the range of clinical scenarios which such a trainee could be expected to manage in a clinical environment, such as ICM patients or Emergency Department referrals.

These scenarios may (but do not always) include emergency events. Scenarios can include paediatric patients, and patients with cardiac or neurosurgical conditions, and may be ‘located’ anywhere an intensivist might expect to be called to review a patient e.g. Emergency Department, general or specialist ICU and HDU or hospital wards (including paediatric, cardiac, general or specialist wards, obstetric unit etc).

We recommend candidates have practice at working with high fidelity simulators before the exam.    

Subjects noted by examiners to have been answered poorly by a number of candidates in this examination were:

• Applied physiology e.g., compliance and flow-volume loops, causes of hypoxaemia, bowel obstruction
• Ventilation strategies in asthma
• Questions on capacity and consent and the legal basis for these

Some candidates likely would score better by answering the exact question being asked rather than talking in general on the topic, and some wasted time by using vague non-medical terms and then having to be asked to clarify e.g., ‘heart attack’ when anterior myocardial infarction was required. Candidates should note that when asked to ‘interpret’ blood results, reading out a list of what is normal or abnormal is insufficient to score marks; a conclusion as to likely causes and relevance (in the context of the other information available within the question) is required. 

In some communication stations a number of candidates, while demonstrating a good communication style, did not actually communicate the important facts of the situation effectively such as, the likely death of the patient. Marks in this station are awarded both for communication style and content. 

In simulation questions, a number of candidates appeared to be expecting an ALS-type cardiac arrest scenario and limited their answer to this. ALS is a foundation competency; FFICM simulation is set at the end of stage 2 ICM training, and while it may include cardiac arrest, it will include more complex issues such as: ventilation strategies, problem solving, diagnostic dilemmas, ethical considerations and balancing of competing priorities.
 

In this exam, in the opinion of examiners, the following topics were not answered well by a number of candidates:

• Transfer
• Applied basic sciences (oxygen question and applied physiology of pregnancy)
• Microbiology and hyperosmolar hyperglycaemia (this was also noted when this question was previously used)
• Oesophageal rupture

In a question on acute liver failure, examiners were concerned that hypoglycaemia was not considered by a number of candidates.

In simulation questions, when dealing with an intubated patient or a patient in cardiac arrest, examiners were concerned that the absence of ETCO2 monitoring was not commented on by a number of candidates. In the SOE, a number of candidates struggled with the questions on neutropenic sepsis and scoring systems. 

A number of new candidate resources are present on the FICM website. Since guidance on how to systematically report an ECG and chest x-ray was published, examiners have noticed that the proportion of candidates who now score well on these questions has improved. 

A number of examination visitors were present at the oral examination – these were all ICU consultants who are involved in training. They commented that the standard of the examination questions seemed appropriate, they saw some candidates who were well prepared and some who were not and noted that in the SOE questions a number likely could have scored higher by using a more structured approach to broad topics.

• Applied basic sciences - pharmacology of commonly used ICU drugs
• COPD
• Septic shock
• Ventilation
• High-fidelity simulation

In this exam, questions on applied basic sciences such pharmacology of commonly used ICU drugs were not answered well, as were those on COPD, septic shock and ventilation. 

Some candidates appeared to have had little experience with high fidelity simulation (despite it being used in the exam since 2013) and wasted time by asking the examiner for clinical signs rather than examining the simulator (which can simulate a number of signs). Some missed important signs by omitting relevant parts of clinical examination (such as looking at pupils in an unconscious patient). Failing to look for relevant signs is likely to make it difficult for a candidate to reach the correct conclusions to be able to score a high mark at this station. A number of candidates seemed to be expecting an emergency, and were observed to call for senior help at the start of the simulation station, or to behave as if a critical incident was occurring, when the physiology and signs displayed were normal or only slightly abnormal. In such situations a doctor in Stage 2 of the ICM Training Programme would be expected to be able to manage the situation. Additional guidance on high-fidelity simulation in the FFICM exam has now been included in the candidate resources sections of the FICM website.

The candidate resources section of FICM website now has clear guidance on how to answer certain questions (such as ECG and radiology) and it was noted that far more candidates in this exam were using a more structured approach to interpreting ECGs in the OSCE, so scored higher marks at these stations.

In the SOE some candidates would have found it easier to score marks by structuring their answers, particularly when asked for lists of items.

• ECG analysis
• Radiology 
• Basic sciences - sodium
• Never events
• Pulmonary hypertension
• Osteomyelitis
• Venous oximetry
• Environment hazards in the ICU

In this exam, ECG analysis was felt to be poor, with a number of candidates not using a systematic approach (so missing areas such as rhythm rate axis) or missing abnormal findings. Radiology, in particular chest radiograph analysis was also felt to be weak for a number of candidates. These topics are noted to be done poorly by a number of candidates in each of the recent exams.

Many candidates had difficulty with the questions relating to the Stage 2 curriculum such as pulmonary hypertension, venous oximetry, brain stem death testing and with also with the applied basic sciences parts of questions such as sodium homeostasis and pharmacology of common ICU drugs. 

Many candidates found the questions which did not relate to a specific clinical presentation challenging e.g. never events and environmental hazards in the ICU. 

Examiners also noted that some candidates would likely score more marks if their answers had been more precise, e.g. saying ‘hospital acquired pneumonia’ instead of ‘infection’ when a diagnosis is requested. 

• Basic sciences
• Radiology interpretation
• Lack of systematic description of radiology images and ECGs 
• Non-invasive ventilation 
• Dermatology as relevant to ICM
• The coroner/procurator fiscal’s process 
• Consent
• Communication with simulated relatives or patients – candidates would benefit from teaching and  feedback in the workplace on these skills.

Examiners noted the lack of systematic description of radiology images and ECGs. It was, however, noted that some candidates did this very well, while others still missed marks by omitting this.

• ECG interpretation, including basic rhythm analysis
• Chest Xray interpretation
• Applied basic sciences, including abdominal anatomy and physiology of cardiac output 
• Knowledge of relevant microbiology and antibiotics
• Critically ill obstetric patient
• Practicalities of oxygen and CPAP therapy
• Renal replacement therapy, in particular the circuit components
• Ethical issues in resuscitation

Marks are lost by stating ‘ask another specialty’ in answer to some questions eg ‘ask a microbiologist’ on antibiotic choice, ‘ask a nurse’ on set up of CPAP; while involving the multidisciplinary team is clearly important; candidates are expected to have an understanding of the management of all relevant ICU conditions and therapies.

Marks are lost by using casual, inaccurate terms and not then clarifying, such as ‘use electricity’ when ‘DC cardioversion’ was required.

Many candidates found the following areas challenging:

• ECG interpretation, including basic rhythm analysis and chest x-ray interpretation e.g. applying basic sciences, including abdominal anatomy and physiology of cardiac output. 
• Knowledge of relevant microbiology and antibiotics 
• Renal replacement therapy, particularly its circuit components and on chronic critical illness.

Examiners also noted that some candidates were not able to answer the questions on a critically ill obstetric patient that included recent national guidance and practicalities of oxygen and CPAP therapy. 

• Basic sciences- pharmacokinetic principles, mechanisms of action of inotropic drugs, lactate production 
• ECG atrial flutter, atrial fibrillation and ventricular fibrillation 
• Sepsis

Examiners noted that many candidates were weak in basic sciences where they were not able to answer questions on pharmacokinetic principles, mechanisms of action of inotropic drugs and lactate production. They also observed candidates unable to recognise common abnormalities in the ECG station. Atrial flutter, atrial fibrillation and ventricular fibrillation should be basic knowledge for a trainee intensivist. 

Candidates failed to consider and recognise sepsis, where they stated they would offer antibiotics to a simulated patient suffering from sepsis which concerned the Examiners. 

In the simulation station some candidates performance was below a level that would be expected in ALS training.

• Osmolality, osmolar gap, hyperosmolar hyperglycaemic states 
• Basic structure of proteins, protein requirements in the critically ill
• Oxygen, hypoxaemia and oxygen delivery 
• Hypercalcaemia and calcium homeostasis 
• Amniotic fluid embolism 

Examiners noted that candidates were struggling with discussing the following topics:

• Osmolality, exploring osmolar gap and leading to a discussion on hyperosmolar hyperglycaemic states. 
• Basic structure of proteins leading onto protein requirements in the critically ill; oxygen, hypoxaemia and oxygen delivery and hypercalcaemia and calcium homeostasis
• Clinical conditions should be expected to be explored in depth even if rare such as amniotic fluid embolism which was covered in the exam.
• Many candidates seem to have received the message about structuring their description of images and ECGs but there were still those losing marks for not referencing basic information such as name and date. 

• ECG
• Communication – using medical jargon when talking to simulated relatives or patients 
• Bowel management systems  
• Short bowel syndrome 
• Acid base balance 
• Basic science relevant to clinical practice

Visitors who observed the ECG, simulator and communication stations highlighted the following:

• Candidates were finding assessing ECG’s difficult. It was suggested that candidates were looking for complicated diagnoses and so missing simple ones such as atrial fibrillation. They noted on occasions there would be a positive finding of minimal significance, such as a small subdural haematoma, that appeared to stop the candidate searching for the real problem.
• Candidates were improving on the Communication Station but some were still inclined to talk in jargon. Although working with members of the public on a daily basis they seem to forget that it is unreasonable to expect the public to have a knowledge of technical terms. Candidates entering the communication station in the OSCE exam may be introduced to a scenario that includes a simulated patient or relative and asked to talk to them. The examiner may say nothing and simply observe. Candidates would do well to remember that the exam uses actors who are members of the public and do not have to act when they profess not to understand what is said to them unless it is in plain English. It is not uncommon to hear the simulated patient ask for a term to be explained such as non-invasive ventilation, tracheostomy, vascath, inotrope or filtration.

Examiners noted that candidates were struggling with discussing the following topics:

• Bowel Management systems such as Flexi-Seal. The candidates, should be aware of the risks and benefits of such systems.
• Dealing with problems experienced by patients with short bowel syndrome. These patients often need critical care support and can be difficult to manage. 
• Acid base balance. The content was mainstream and not well answered by candidates. It is important that candidates are familiar with basic science relevant to clinical practice. 

The A-line (Anaesthesia Learning in the North East) FFICM VivaMatch course provides candidates with unprecedented peer-to-peer viva practice opportunities in the run-up to the exam. It runs over Zoom and works around existing schedules so candidates are only matched into sessions they are marked as available for. The course runs over a 5 week period ending just before the exam sitting, providing exposure to questions from a variety of peer-examiners and opportunity to fine tune exam technique as the course progresses. Their website for further details is as follows: https://www.a-line.org.uk/events/final-fficm-vivamatch/

The London FFICM Course is a well established course with the aim of providing an intense but rewarding day of both SOE and OSCE practice. The course has been run successfully - both in person and virtually during the pandemic - for a number of years. Our experienced faculty, consisting of consultants and post-FFICM senior trainees, try to closely recreate the exam experience for candidates. The course has had great feedback and been of huge benefit to those sitting the final FFICM examination. For further information and updates about upcoming courses, our email address is londonfficm@gmail.com and our Twitter handle is @LondonFFICM

Questions from the entire breadth of the FFICM syllabus, quizlet format. Long and short SBAs Answers and references provided. Zoom format, one day intense course. FFICM qualified instructors. Subspecialist input. Interactive sessions and take home material.  

Email: ficmcoventrysba@gmail.com

Website: https://www.mededcoventry.org/Courses/Anaesthetics/FFICM-SBA-Course

FFICM Exam prep course  run out of Guy's, King's and St Thomas's Hospitals

Consultant Faculty from: Guy’s, St Thomas’ & Kings College Hospitals

• Exam technique and strategy
• Personalised feedback
• OSCE circuits
• SOE circuits
• Hot topics

LOCATION: Weston Education Centre, Denmark Hill  FREE: for GSTT/KCH employees

Course Directors: Dr S Sparkes, Dr J Meyer RSVP to: simon.sparkes1@gstt.nhs.uk

An intensive 2-day course of very high standard SOE and OSCE practice with experienced examiners who have passed the FFICM exam. We replicate the face-to-face (or virtual) FFICM examination conditions and we push the ability of the candidates who have done sufficient work in preparation for the FFICM exam. The main objective of the course is to help the prepared candidate improve their exam technique and identify important gaps in their knowledge relevant to the FFICM curriculum. On this course we are moving away from didacticism to a candidate-centred learning approach. 

More inforamtion about the course can be found on their website. 

The Oxford FFICM course has been running since 2013. The venue alternates every 6 months between the John Radcliffe Hospital, Oxford (Spring) and Milton Keynes University Hospital (Autumn).

The morning is dedicated to OSCEs, the afternoon to SOEs and the emphasis is very much around exam technique and re-creating the ‘exam experience’ for candidates. Our consultant and post-FFICM faculty are always highly praised for their friendly, constructive feedback and knowledge of the exam process.

New faculty are always welcome. Breakfast, lunch, tea/coffee are included along with a trip to the pub afterwards for drinks and a bite to eat. We can also cover reasonable travel expenses. If interested, please contact richard.stewart@mkuh.nhs.uk

More information about the Oxford SOE/OSCE course can be found on their website.

PINCER is an established course run by the team in Portsmouth and Wessex. Click here for more information.

This 2 day course is delivered by Critical Care Consultants and senior ICM StRs from the Southwest and provides an opportunity to hone your FFICM OSCE and SOE skills. Previously delivered virtually we will be face to face from Autumn 2022. Expect workshops on ECGs, radiology and data interpretation as well as plenty of practice talking out loud with individualised feedback for every station.  Previous candidates have said "Fantastic course, cannot recommend enough", "Really positive faculty - excellent organisation", Feedback was of a high quality".  Priority booking for Severn and Peninsula trainees. Their website is: https://sppice.org.uk

Another 1 day SOE/OSCE course, the Stoke-on-Trent course website is here.

SOE/OSCE course with consultant examiners and senior ICM StRs with one-to-one feedback in the weeks immediately preceding the exam, run twice per year.

An all day course where candidates receive talks covering non-clinical aspects of the exam, ECG and radiology followed by a full morning of OSCE practice and full afternoon of SOE practice. Priority booking for Wales deanery trainees, thereafter spaces available on first-come-first-served basis, with remaining candidates on waiting list.

All enquiries please to: thewelshcourse@gmail.com

This is an exam prep course run for free for all Y+H ICM trainees consisting of two Viva mornings and one OSCE morning in the weeks immediately prior to each exam sitting. Places are usually limited to regional trainees due to limited faculty. However, external candidates can enquire about cancellations to fficmprepyorks@gmail.com.