The FRCEM exam has recently been re-structured and the format altered. Previously there were two separate exams, the MRCEM and FRCEM examinations. These have now been merged into a single examination that will take the candidate all the way through their training from the foundation years until they become a consultant.
The FRCEM Intermediate Certificate is the second part of the new FRCEM examination and is sat twice yearly.
The FRCEM Intermediate Exam Breakdown:
The FRCEM Intermediate paper is three hours long and comprises 60, three mark short answer questions (SAQs). The majority of the questions are 2 or 3 parts and some questions require two answers to earn a single mark i.e. each answer is worth half a mark.
The exam is mapped to the competences of Year 1-3 of the Emergency Medicine 2015 Curriculum (ACCS Plus), which is available on RCEM website. All applicants for the FRCEM Intermediate Certificate examinations are strongly advised to familiarise themselves with the Year 1-3 competencies in preparation for sitting the FRCEM Intermediate Certificate examinations, which can be found in the 2015 curriculum here.
The FRCEM Intermediate examination is mostly clinical and tests topics that are commonly encountered in the Emergency Department setting. The areas tested include:
- General medicine
- Trauma & Orthopaedics
- Maxillofacial surgery
- Obstetrics & Gynaecology
- Ethics & Law
The exam is marked using a modified Angoff method where a cutoff score is defined as the score a minimally acceptable candidate is likely to achieve. One standard error of measurement will be added to the cutoff scores identified using the Angoff method to calculate the required final pass mark for the paper.
The FRCEM Intermediate Question Style:
The questions in the FRCEM Intermediate exam are short answer questions (SAQs). SAQs require the ability to formulate an answer based on the information given in the question without the advantage of having options to choose from. They usually take the form of a clinical scenario followed by a list of questions that require knowledge about the subject matter presented.
The answers to the questions are usually agreed upon by a board of examiners before the examination. Additional answers encountered in the marking process can be added to the marking scheme if they hadn’t been thought of initially and they are agreed to be appropriate by the examining board. For this reason they are an excellent means of assessing candidates but require a great deal of input.
An example of a typical FRCEM Intermediate SAQ is shown below:
A 60-year-old man presents with dizziness and palpitations. Whilst in the Emergency Department the following rhythm strip is recorded:
(a) What is shown on the rhythm strip? (1 mark)
Torsades de pointes
(b) Which drug treatment should be initiated (please include dose)? (1 mark)
1-2 g of IV magnesium sulphate over 2-3 minutes
(c) Give an electrolyte abnormality that is commonly associated with this condition? (1 mark)
Torsades de pointes is a specific form of polymorphic ventricular tachycardia that occurs in the presence of prolongation of the QT interval. It has a very characteristic appearance in which the QRS complex appears to twist around the isoelectric baseline.
A prolonged QT interval reflects prolonged myocayte repolarisation due to ion channel malfunction and also gives rise to early after-depolarisations (EADs). EADs can manifest as tall U waves, which can cause premature ventricular contractions (PVCs). Torsade de pointes is initiated when a PVC occurs during the preceding T wave (‘R on T’ phenomenon).
It can be caused by any cause of prolongation of the QT interval:
- Myocardial infarction
- Electrolyte disturbance e.g. hypokalaemia, hypomagnesaemia and hypocalcaemia
- Congenital e.g. Romano-ward syndrome and Lange-Nielson syndrome
- Drugs e.g. disopyramide, amiodarone, sotalol, terfenadine
The drug treatment of choice for torsades de pointes is IV magnesium sulphate. Magnesium sulphate acts by decreasing the influx of calcium and lowering the amplitude of EADs.
DC cardioversion is usually kept as a last resort in a haemodynamically stable patient because of the paroxysmal and recurrent nature of torsade de pointes.
Torsade de pointes can degenerate into ventricular fibrillation and result in sudden cardiac death.
Preparing for the FRCEM Intermediate
Although the FRCEM Intermediate exam does not have the daunting volume of knowledge required for the FRCEM Primary it is still a difficult and challenging examination. Many of the questions take on the form of data interpretation, with questions based around blood tests, an X-ray or an ECG. Candidates should start preparing at least 6 months before the examination.
Feedback from candidates that sat the first new style FRCEM Intermediate examination in September 2016 emphasized that getting through the exam in good time was difficult. Many struggled to complete the entire paper in time and few managed to re-read and check their answers. For this reason it is strongly recommended to practice answering questions under timed, exam conditions if possible. Try using an online resource that offers timed mock exams, such as our website.
The Oxford Handbook of Emergency Medicine is an excellent resource for the FRCEM Intermediate examination and once purchased will probably remain at your side for much of the years that follow during your Emergency Medicine training.
Other frequently tested aspects of the FRCEM Intermediate examination are scoring systems and clinical guidelines. It is a good idea to familarise yourself with the various scoring systems used in the Emergency Department setting, such as CURB-65 for pneumonia and ABCD-2 for TIA assessment. You should also attempt to read relevant NICE and SIGN guidelines.
The FRCEM Intermediate examination is very closely matched to your every day work in the Emergency Department so it is a good idea to read around interesting and relevant cases that you come across in day-to-day practice as this will help you to achieve a better understanding of current practice and guidelines.
Good luck with your exam preparation!
Thank you to the joint editorial team of FRCEM Exam Prep for this ‘Exam Tips’ blog post.