Last updated 25 September 2006

DIPLOMA IN INTENSIVE CARE MEDICINE

APRIL 2006 SITTING

REPORT BY THE CHAIRMAN OF EXAMINERS

An initial application, in the form of an outline, to sit the examination was received from 35 candidates. Of these, 24 eventually presented a formal application, including 5 of whom had higher degrees. Eventually, 22 candidates attended for examination and 20 were passed by the Examiners. This brings the number of Diplomates in the United Kingdom to 68.

The examination consisted of 5 oral examinations as detailed below. For those who had submitted a dissertation there was a dissertation oral. There was then a clinical and data analysis examination which consisted of a long case, where a written clinical scenario was available to the candidate for 10 minutes prior to the oral examination, which was then explored by the examiners. There then followed 3 short cases, which were based on an ECG, an X-ray and on blood tests that might be seen in the clinical environment, leading into a discussion of the case. In a further oral examination the candidates were examined on the 10 selected cases they had submitted. Finally, there were two oral examinations, both based on two structured questions.

Dissertations

These were generally strong. The dissertations were well written and the candidates usually knew their subjects and could defend them. Areas of weakness included some search strategies which were poorly defined. For example, if only English language papers are to be reviewed, this should be stated. Clearly, searches on some topics will yield vast numbers of references, and so being able to explain how these were sifted for relevant papers and how these were chosen is a sensible matter to consider. There are acknowledged methods of assessing the value of a paper which are well worth reading; one such guide, used by JAMA, can be found at http://pubs.ama-assn.org/misc/usersguides.dtl.

Occasionally the conclusions seemed inappropriately weak given the information in the dissertation. If there are clearly stated objectives at the front of the dissertation then these should be addressed in the conclusion.

Clinical scenario and data interpretation.

This was a new section and as previously described comprised a long case and several short cases. Performance was weaker than might have been expected in this area. Examiners were looking for a methodical approach to a clinical problem using the information provided to derive a differential diagnosis and a reasonable line of management, in a similar manner to that which happens in clinical practice. This occasionally posed some difficulties where there was an unstructured approach to diagnosis and management. Similarly, in the short cases, some difficulties were encountered because of a lack of a methodical approach to reading and interpreting an ECG or chest X-ray; likewise with blood gas and electrolyte results. The examiners were looking for a methodical approach to ECG, X-ray and blood gas interpretation rather than an immediate spot diagnosis. In each case, a method of describing the data, its abnormalities, and then giving a differential diagnosis, was what was expected. Interestingly, interpretation of a CT scan of the brain showing a subdural haematoma seemed to pose fewer problems than a chest X-ray with a pneumonic picture in a patient with TB. In each case a methodical approach would have identified the important abnormalities, and in the latter case could lead to a differential diagnosis. Reading ECG, X-rays and blood gases is part of everyday practice; despite that, it did seem that some benefit could have been gained by time spent looking at X-rays with radiologists, ECGs with cardiologists and blood gases with colleagues in the ICU, and by revisiting basic methods of reviewing these tests.

Selected case summaries.

This was a strong section; the cases were presented as might be seen in a journal. The relevant details in a case presentation leading into a focused discussion and review, often with a limited number of appropriate references, were helpful. It is wise to know the details of the case and to have a reasonable depth of knowledge of the material covered in the review.

Structured oral examinations

These covered two main topics in both of two oral examinations. The topics were diverse and covered several aspects of intensive care, all listed in the syllabus. On this occasion the surviving sepsis campaign was considered a 'hot' topic and as such one that should be known, and about which there should be both knowledge and opinion. The examiners expected not only a reasonable knowledge of this topic but also the ability to discuss the evidence base and any aspects that might be changing or be considered controversial. Other questions included methods of monitoring cardiac output and also capnography. The examiners expected a reasonable working knowledge of what was available, its applications and limitations, and also opinions on how the technology has been or might be used. One question addressed HIV in the ICU context, and whilst this might be considered specialised, the examiners considered that HIV might easily present to any ICU, and so is a reasonable topic for intensive care. The examiners expected a working knowledge of the subject as it applies to ICU, and an awareness of some of the problems with management, but were not expecting detailed specialist knowledge of the latest HAART regimens, even from those working in specialist centres. Other topics included subarachnoid haemorrhage which as a 'bread and butter' topic for an intensivist seemed to pose few problems, as did the acute coronary syndrome.

Conclusion

Overall, the examiners were impressed by the performance of the candidates, who were well versed in current intensive care practice and easily capable of demonstrating not only knowledge but also opinion. The standards achieved by the candidates reflect well on the UK training programmes, and bodes well for the future.