The 2006 Experience

The exam seems to have changed a bit in 2006. Firstly, there's a new section, the clinical material viva; and secondly, there seemed to be a bit more emphasis on general medicine and anaesthetic sciences, and a bit less on current ICU literature. With a record sitting of 22 candidates, I'm particularly grateful to these four candidates for their accounts. The report of the Chairman of Examiners can be found here.

© James Austin 2006

 

I was one of the lucky 20 who passed the 2006 sitting. Here are my thoughts on the exam. The following are my personal views so read and ignore at your leisure!

Dissertation tips and hints

Choose a dissertation topic that:

  1. - interests you (it’s got to interest your examiners too)
  2. - is unlikely to be the pet subject of any of your examiners (unless you are extremely confident)
  3. - is of some real clinical relevance to intensive care medicine (otherwise you might face the question ‘so what?’)
  4. - can be concisely covered within the word limit (my own topic was quite broad and therefore led to a lot of heart rendering editing)
  5. - and if possible, is original (as the exam is now a few years old and the examiners haven’t really changed many of them will have read several dissertations on subjects such as pro-kinetics, post cardiac arrest hypothermia and low tidal volumes in ARDS; although these are relevant to practice you don’t want to be judged against a previous candidate who wrote a better version on the same topic).

Also:

I have to admit that I didn’t start to revise for the exam itself until after my dissertation was signed, sealed and delivered but then I did take some annual leave to break the back of the heavy work. As for revision texts/materials; I used this excellent website’s literature hitlist, The US book ‘Critical Care Secrets’ (via amazon), the Cochrane database’s guide to writing a systematic review (good for stats) [see also Cochrane's Open Learning programme, which covers much of the same ground - Ed.] and wikipedia (excellent for simple explanation of statistical methods).

The exam itself is a hard day. The exam has changed since 2005. Unfortunately, there was a minimal amount of pre exam information sent out to us regarding these alterations and as a result we entered the exam hall a bit in the dark.

The new data analysis section was very clinically orientated and very much like the cases on the old MRCP exam. It consisted of a ‘paper long case’ with a few minutes preparation to read a potted history and see some biochemistry and blood gas results. The viva which followed was very much of a discussion format. I don’t think there was a definitive answer regarding a diagnosis but all the aspects of the case were probed quite deeply. This lasted about 15minutes and was followed by an ECG case, CXR case and some further blood investigations.

The dissertation viva was very in depth (be prepared to defend your conclusions, understand the statistical methods used in your key references and be aware of any failings/ bias in your analysis).

The ‘general ITU’ vivas were limited in scope; four main questions in 1 hour; Sepsis, acute coronary syndrome, capnography and cardiac output measurement, and status epilepticus. It helped to have done a bit of medicine. I thought the subjects were slightly leftfield but they were on the syllabus.

In conclusion, I’m glad I took the exam, the main benefit was that it forced me to learn my subject. The dissertation is very hard work and I suppose in comparison to it the vivas were the easy bit. Via informal feedback I was told that people generally fail on the dissertation viva and case report vivas, as the examiners take the view that if you wrote it you should be able to talk coherently about it.

Good luck for next year and it is worth it (now)!

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Please feel free to edit this/completely ignore but I felt compelled to write a few notes about today's exam before I forget!

Chatting to the other candidates, we all regarded your website as the only resource for info regarding the DICM and it was an absolute godsend so keep up the good work! [*modest blush* - Ed]

Okay, down to business.

My dissertation: In retrospect, I picked a poor topic for a systematic review, as the evidence for my topic is such poor quality - so my top tip no. 1 is ‘pick a dissertation with at least some high quality evidence on’ and try to pick a well defined problem.

Dissertation viva: This was extremely pleasant, even after me nearly shooting myself down in flames by making a terse comment about surgeons only to find one of the examiners was a surgeon! Despite that faux pas, the questions were extremely fair and involved me taking the examiners on a whirlwind tour of all things abdominal. We spoke solidly for an hour but you really must know your dissertation inside out. I think one of the differences between this exam and the ones I’ve previously taken (MRCP & FRCA) was that for a lot of the exam, there are no absolute ‘right or wrong’ answers to the questions and the examiners are looking for a balanced knowledge of the various arguments for and against.

Clinical material viva: This was the first time this new format has been used and so we really didn’t know what to expect. In fact, it was a very similar format to the FRCA final. We were given some clinical material (history and few blood tests) and given 10 minutes to analyse them before being led in to the first 30 minute viva. This consisted of 15 minutes on the case material followed by a further 15 minutes looking at CXRs (I had a rather impressive left upper zone cavitating TB lesion) and ECGs (trifascicular block). Each piece of material was followed by the predictable questions regarding subsequent management. The last bit was a few blood tests basically describing an obstetric haemorrhage case leading us to the management of severe haemorrhage ending with the role of recombinant factor VIIa.

The second half hour viva was on the Case Summaries. Again, this was fair with questions covering approx 6 of my topics. I would advise anyone currently deciding on their case histories to choose ones that will aid their general ICU revision and not something too ‘hens teeth’. Make life easier for yourselves!

The afternoon’s general viva was also split into two with pre-written questions. The first was on the Surviving Sepsis campaign and was similar to that asked in previous years regarding knowledge of levels of evidence & recommendations and a chance for us all to dribble out our carefully rehearsed knowledge of the sepsis literature. This followed on to a discussion about acute coronary syndromes, their pathophysiology, diagnosis, management, secondary prophylaxis etc etc (seemed a bit medical to me!). The final bit was about withdrawal and withholding therapy and was a chance to say something controversial and then run for cover!

The next viva started off with a discussion about end-tidal CO2 monitoring (which I felt was a little harsh on the medics) and was precisely FRCA primary material which I was forced to delve into the memory banks for! We then moved on to a discussion of status epilepticus: cerebral pathophysiology, mechanisms of cellular damage and then (thankfully) on to management and a bit of pharmacology of the various agents used for its treatment. We finished up with a brief discussion of cardiac output monitoring and the physics behind the oesophageal Doppler.

Impression overall: very fair exam but with such an enormous ‘syllabus’ you really had to have done your homework. That being said, I spent all my time reading up on the latest advances & papers on each of the ‘core domains’ and really the only ‘current’ stuff I needed was the surviving sepsis material.

In retrospect, a core ICU manual such as Oh’s Intensive Care is the ideal revision guide, and I would suggest prospective candidates base their general revision on this. Assuming the format we experienced is the way the exam is moving, then a general appreciation of the entire scope of ICU is required rather than in depth, up to date knowledge of the ‘sexy’ topics.

Current Opinion in Critical Care was a great resource however, as were the editorials in Critical Care Medicine for an overview of the more interesting aspects of ICU.

I’m glad I did the exam, but it’s a lot of work and you really need to be committed to put yourself through it.

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I have just taken (and passed) the Diploma in 2006. For the stats: 22 candidates pitched up over 2 days (3 ladies); 20 passed.

There is a new format as follows:

1) 1 hour dissertation viva with 2 examiners (candidates were allowed to bring the dissertation into the viva, which helps a lot)

2) 30 min viva over a "long case + other clinical test" (i.e.ECG, CXR, lung function test etc.) with next 2 examiners. 10 minutes preparation to look at long case (story, preliminary data) then 20 minute discussion.

3) 30 minute viva on the 10 expanded cases (new examiners). Again hard copies of your cases were allowed in the viva.

4) 1 hour "free viva" , split into 2 halves with 2 sets of examiners. 2 questions only per 30 minute session on anything under the sun.

I found the exam very medically orientated (panhypopit patient in long case; trifascicular block ECG etc.) and sadly they seem to try and include everything again (i.e. all the FRCA syllabus). I was asked about the technical aspects of Capnography and ended up chatting about indirect calorimetry and the jolly old days when you plug it into the Servo 900, but then it never worked and went out of fashion about 15 years ago!!! I have only been in medicine for 10 years - what was that all about? The colleague from a medical background was nearly in tears about this as capnography for him is a little box that gives you a nice number.

No talk about any recent studies or controversial stuff, if you have good medical knowledge and have read a good textbook the chances seem to be as good as any. Doing an advanced ITU job does not confer any additional benefit in my opinion.

Sadly that makes your literature hit parade less useful, and spending a lot of time on it (it is well compiled by the way) does not seem to pay off in pure exam terms.

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Phew! Tough exam in the sense that you have to do a lot of talking- but I guess that is why you call it an viva!!

Dissertation: this was the bit I was most worried about. In the hour you really do have to explore virtually every aspect of your dissertation, from the method of the literature search through to any clinically relevant points you made, and justify them. But examiners were very friendly and the questions were more analytical than factual in the main.

Clinical viva: New bit to the exam, more of a discussion around the topic than anything else. Given ten minutes to look at a potted history and a CXR then had to present it and talk though the investigation and management of it. I had an elderly lady with a 2-week history of non specific viral illness, an abnormal CXR, presenting with respiratory failure and acute cor pulmonale, improved a bit on diuretics then developed refractory hypoxaemia. I thought it was more likely to be an atypical pneumonia from the history and results, was dragged thorugh investigation and management of her when 10 days later (and no positive microbiology) she was no better. Talked about role of lung bx- was it indicated (maybe), was it done often (I said in my practice very rarely but was to look for BOOP etc). Told me she had Wegener's in the end, I was surprised and no other symptoms- but don't think it was a pass or fail issue more to see if you can think through a problem. Next case was of ECG with LBBB- no other info given. Had J waves and therefore got on to discussion of rewarming how one does it, how would you do it in this patient. Third case was of hyperchloraemic metabolic acidosis and differential; and finally CT head of bad SDH - management strategy etc etc.

Case summaries:quick blast through new cardiac arrest guidelines, prognosticating on outcome from cardiac arrest, use of PA catheters in cardiogenic shock, how to calculate LVSWI, does SvO2 influence outcome, what targets would i use initially, when would I withdraw. Only advice to give for this is know your summaries well.

Afternoon vivas were the structured questions. I got asked about diagnosis, prognosis, management, risk factors of SAH, Surviving Sepsis Campaign guidelines, critical discussion of aPC - had I seen any problems, what about use in renal failure, APACHE scoring and should this be used as screen - brief mention of the relevant published trials. Then diagnosis and management of HIV patient, history, risk factors, aetiology, treatment issues (HAART, prophylactic antibiotics) improved survival over time or not, then got into a general discussion of antifungal agents and antiviral agents. Second part of the viva was on cardiac output monitoring on ICU- what methods were there, how did they work and asked to choose one to talk about in depth. I chose the LiDCO, but also had to talk about pro and cons of various devices and their limitations and any evidence of benefits or harms ie especially about PA's

So what are my tips for the exam? Think about your dissertation carefully and know it and your case summaries well. Use your case summaries to cover a good proportion of the literature. Don't obsess about knowing every single paper for the last 20 years but do know about the major ones currently and be able to critique them. I used 5th edition of T.E Oh's Intensive Care Manual which I thought was good. Critical Care Secrets is quite old fashioned in some of the chapters BUT covers everything you are likely to be asked. Current Opinion is variably good. Critical Care is a good on-line resource and manages to be current and up to date with hot topics.