CICM Primary Exam Syllabus review

This chapter refers to the historical syllabus documents used by CICM to describe the body of knowledge expected of the junior ICU trainee. These evolve with time, and their fossil record is highly informative:

From 2014 to 2017, the most noticeable changes between the syllabus documents had been:

  • Removal of the statistics syllabus (presumably, this has migrated to the Part II Exam) - this remains here as a historical footnote and to help trainees who are looking at the old papers, but the majority of statistics revision notes will have a new home in the Statistics and Interpretation of Evidence section from the Required Reading archive for the CICM Fellowship Exam. 
  • Removal of the toxicology syllabus (the SAQs which belonged to this category have since been distributed to other sections, in a fairly arbitrary manner)
  • Abbreviation of (previously already neglected) topics such as pharmaceutics.

The next iteration of the syllabus will be active from the second paper of 2024.

Changes from 2017 to 2024

What would one do with one's early pre-dawn Sunday, if not convert the College syllabus statements into word documents and compare them side by side like some kind of obsessive weirdo. Apart from, decapitalising some of the previous Weirdly Capitalised Words in the introductory material the opening section reads the same and can still be safely ignored, with the exception of the question vocabulary. The addition of "calculate" and "compare and contrast" is helpful, though not as helpful as  would be to specify an accepted structure for answering questions that start with the very similar terms "describe", "explain" and "outline". Also conspicuous by their absence are levels of understanding (L1 and L2), except for the pharmacopeia, where a third level (L3) was added, presumably indicating a level of vague nonspecific awareness.

Recommended texts have been fortified with the addition of Boron and Boulpaep for general physiology and Milner and Welch for pharmacology. Stoelting and Neal have been removed from the list of "additional texts with useful sections", presumably in recognition of the fact that those sections weren't useful. “Mims' Medical Microbiology and Immunology” by Richard Goering et al has replaced "Immunology at a Glance" by Playfair & Chain. 

Unfortunately, the physiology textbooks are presented as arguments of an "OR" function, which suggests the trainees can choose between them and select one book with the expectation that each will fulfil the main goals of the syllabus equally well. This is probably wrong because "Ganong's Review" and Guyton & Hall definitely contain less detail than "Medical Physiology” by Walter Boron and Emile Boulpaep, the latter being widely regarded as the most comprehensive student-grade physiology resource (before you move on to major reference works such as Comprehensive Physiology) . This is obvious even from a crude comparison suchn as a page count, with the third edtioion of Boron and Boulpaep totalling 1312 pages, vs 686 and 1096 for the other two. Obviously this has implications for how much detail the trainee ends up expecting to memorise and understand. Consider as just one example: Ganong allocates two paragraphs to the alveolar gas equation, whereas Boron & Boulpaep offer a rigorous mathematical derivation and proof. Obviously the CICM exam candidate will develep a different impression of what expectations are placed upon them, depending on which textbook they decide to read, and this expectation may not match the expectations of the examiners (as they might have decided to get their marking rubric from a totally different textbook).

The syllabus sections have been renovated extensively, and appear to be simplified wherever possible. For example, where previously Section B(i) of Pharmacokinetics had been  "explain the concept of pharmacokinetic modeling of single and multiple compartment models", it now reads only "explain single and multiple compartment models", which is exactly the same entry but better. It should be easier to blueprint an assessment from these items. On the other hand, other sections have undergone the sort of changes to which one might subject a document in order to make it appear as if it had undergone some processing instead of being directly plagiarised, for example where in F(i) "describe the function and structure" has been changed to "describe the structure and function". These apparently cosmetic changes actually serve a purpose by standardising the structure of the syllabus items, i.e. everywhere structure now precedes function, which is a commendable trend towards the sort of meticulousness that people have come to expect from ICU doctors. 

Some carefully chosen changes:

Pharmaceutics no longer contains the cryptic A(i) section, which had previously just read, "A more detailed knowledge would be expected for more commonly used drugs".  The section now only contains one entry, and makes sense. 

Pharmacokinetics no longer has "objectives", which were previously expecting the candidates to develop "an understanding of the fate of drugs in the body, including dosage, and how it is affected by extremes of age, obesity, pregnancy (including foetal) and disease (particularly critical illness)". This statement has migrated to the pharmacopeia in a largely unchanged form, disadorned by the loss of the archaic term "fate", which will be sadly missed. Fortunately this represents a drift towards improved clarity, for example where previously weird "explain the concepts" were replaced with simply "explain". The section grew by one item, but functionally remained the same, as the old two-headed B(v) got split into two separate items ("explain the concepts of intravenous bolus and infusion kinetics. To describe the concepts of effect-site and context sensitive half time").

Pharmacodynamics also lost the duplicate objectives statement which repeated the brief about "extremes of age, obesity, pregnancy " etc. Apart from a rearrangement of syllabus items by number, the only changes here appear to have been grammatic. 

Variability in drug response  was also adjusted for grammar, and is shorter for loss of an item, though functionally it remains the same because D(vii), "outline genetic variability", fused with D(viii), "explain the mechanisms and significance of pharmacogenetic disorders".  The influence of multisystem disease, i.e. "alterations to drug response due to pathological disturbance with particular reference to cardiac, respiratory, renal and hepatic disease", is now represented by the much clearer and more flexible "describe variability in drug responses due to critical illness". 

Cellular physiology did not change overmuch. The nucleus is now mentioned among the organelles, as if you'd miss it if it weren't explicitly listed.

Respiratory physiology has become shorter, with some notable deletions:  

  • Neonatal and paediatric airway anatomy has been expelled, presumably exiled to the Second Part exam (though there is no mention of them in the Second part syllabus either).
  • All mention of the Haldane effect and the chloride shift have been removed (but one can be sure they will keep asking questions about them)
  • Abnormal haemoglobin species have been removed; presumably this does not mean that one can just ignore carboxyhaemoglobin and methaemoglobin during their revision, but it does mean that they should not form the core of an SAQ in the future.
  • Arterial blood gas interpretation is no longer an "ability" expected in this section.
  • Trainees are no longer expected to "outline the methods used to measure ventilation-perfusion mismatch."
  • Some previously two-headed syllabus items have been separated:
    • Compliance and "the elastic properties of the respiratory system" are now separate items
    • "Measurement of lung volumes and capacities and factors that influence them" are now separate items
  • Some previously separate items have fused:
    • "Explain ventilation-perfusion matching and mismatching"  is now together with "explain the effect of ventilation- perfusion mismatch on oxygen transfer and carbon dioxide elimination."
  • Some interesting additions have appeared:
    • "The role of endogenous nitric oxide in ventilation and perfusion" is new, though for some reason it appears in the section dealing with the diffusive transfer of respiratory gases, whereas the role of NO is mostly relevant in VQ matching.

Cardiovascular physiology has also experienced some notable changes include deletions:

  • The whole G5 section, "control of circulation", has been deleted or reassigned  The vasomotor centre was dismissed from the syllabus, as was the role of the autonomic nervous system in controlling systemic vascular resistance and redistribution of blood volume and the humoral regulation of blood volume and flow. These were replaced very efficiently by "explain the cardiovascular responses to ... hypovolemia"
  • Trainees are no longer expected to "explain the derived values from common methods of measurement of cardiac output including transpulmonary thermodilution and pulse contour analysis devices (e.g. variables such as EVLW, GEDV, SVV in addition to CI, SVI, SVRI, LVSWI etc.)​​​​​". However, the "values obtained" by methods of cardiac output monitoring remain, suggesting that the examiners reserve the right to ask SAQs about LVSWI if they want.
  • The word "detailed" was excluded from Section G7(i) which asks the exam candidate to "understand the pharmacology of inotropes and vasopressors", presumably because the pharmacopeia section now clearly defines which drugs must be known thoroughly. 
  • Capillary sphincters are no longer listed as a specific Thing to Know in the section on Starling forces
  • We are no longer required to explain the cardiovascular consequences of obesity.
  • Duplicate items with perplexing differences in the wording (eg. F6(iii), "explain the systolic pressure-volume relationships of the ventricles and their clinical applications") were removed, whereas others were created  - for example G1(ii), "describe the coronary circulation and its regulation", and the similar item G4(iii). 
  • The "pharmacology of adrenoreceptor blocking drugs" has been absorbed into "pharmacology of anti-hypertensive drugs".
  • Regional circulations have been duplicated:
    • All the regional circulatory system items have been distributed to their specific organ section, i.e. renal blood flow now appears in the renal section.
    • The old entry for these remains in the peripheral circulation section, but is now for some reason split into two items, where one item simply reads "These include but are not limited to the cerebral and spinal cord, hepatic, and splanchnic, coronary, renal, and utero-placental circulations"
  • New items have been created:
    • "Explain the measurement of central venous pressure, the components of its waveform and the factors that determine its magnitude" is new
    • "Orientation of the heart" is a new appendix to cardiac anatomy
    • Whereas previously we had to "describe the function of baroreceptors and to relate this knowledge to common clinical situations", the item now contains explicit instructions regarding which clinical situations are intended, as in "explain the cardiovascular responses to changes in posture, hypovolaemia, a fluid bolus, anaemia, exercise, and aging"

Renal system remained largely untouched, except where the specific functions of the kidney (eg. endocrine function, role in acid base, etc) were subsumed into the overall functions of the kidney. The pharmacology of dialysate now has its own item, and cystatin C has for some reason appeared in the measurement section.

Body fluids and electrolytes has not changed very much, except that to know the composition of body fluids is now an explicit expectation, and "estimating" has replaced "measuring" where it comes to the  discussion of the volume of body fluid compartments. The pharmacology of colloids and crystalloids is no longer specific to those "used in Intensive Care Medicine" which theoretically means that weird dextrans and embalming fluid are on the menu.

Acid-base has undergone a minor rearrangement of the order of items, and contains a directive to "differentiate arterial from venous blood gases", but is otherwise unchanged.

Nervous system - including pain  has  undergone some welcome streamlining. For example, "factors affecting and control " has become simplified as "determinants" when it comes to intracranial pressure.

The physiology of sleep has been removed from this syllabus, and it will not be missed. Notably, all mention of toxicology has been removed from the items that deal with local anaesthetics and antidepressants, and NSAIDs no longer have their own syllabus item, being absorbed into "pharmacology of drugs used to treat pain".

 Musculoskeletal system is almost identical to the old version, except now "pharmacology of neuromuscular blocking drugs" and "reversal agents" has fused into one entry.

Autonomic nervous system is completely identical to the old version, except for some grammar.

Liver physiology has become much clearer, having dropped the old functional division of the liver into "storage, synthetic, metabolic, immunological and excretory", which made revision more difficult and split important information into ill-fitted categories, which a move in the right direction. Functional anatomy has been added as its own item, and anatomy of the biliary tree has been removed.

Gastrointestinal system has specifically identified oesophageal sphincter function as the main focus of the sphincter section, which is fair (the other sphincters are of a lesser interest). Octreotide and terlipressin are now lumped together and vasopressin was added. 

Nutrition and metabolism is preserved in an essentially unchanged state, except for some reshuffling of item content

Haematology  has had a few mostly cosmetic changes (for example "process" of crossmatching is now "principles" of crossmatching ). Interestingly "storage lesions" were added, just as we have all decided that they do not matter. 

Thermoregulation  has jetissoned some ballast in the form of " mechanisms for the loss of heat produced in metabolism, and the generation of additional heat" which seems to be such an integral part of "mechanisms by which normal body temperature is maintained" that it must have seemed a shame to separate those into distinct items. "Temperature regulation specific to the neonate" was also set free, presumably because this is not a thing an adult intensivist will ever need to contemplate.

Immunology and Host Defence now fuses anaphylaxis with hypersensitivity, which is fair. Pharmacology of drugs used in the treatment of anaphylaxis has been expelled, perhaps because adrenaline and steroids are already discussed in the cardiovascular/autonoic/endocrine sections. Immunoglobulin is now the sole occupant of the immune pharmacology section.

Microbiology has undergone a grammar check (though, bafflingly, "describe the classification bacteria"  is now "describe the classification of bacterium")  but is otherwise unchanged

Endocrine system  is entirely unchanged 

Obstetrics  no longer needs you to know about the changes in pharmacokinetics and pharmacodynamics during pregnancy, and the prescriptive list of agents  ("oxytocin derivatives, ergot derivatives and prostaglandins", etc) has been reduced into the much more flexible "oxytocic /tocolytic drugs".

Principles of Measurement and Equipment  has lost the measurement of flow, pressure and volume of gases, though presumably this is still expected via the item on "the laws governing the behavior of gases and liquid".

Procedural Anatomy has dismissed all mention of brachial, axillary, posterior tibial and dorsalis pedis arterial line insertion, perhaps reflecting on the knowledge that most of the examiners have never in their life placed a posterior tibial art line.  These removals are welcome in the same way as the anatomy of the bronchial tree relevant to bronchoscopy was a welcome addition, as the whole section has now drifter further towards relevance.

As a counterpoint to the occasional snarl above, those who have a bone to pick with the 2023 CICM Primary Syllabus, or who (like this author shamefully admits of himself) have nothing better to do than to take cheap shots at the grammar or wording, are reminded that it takes an enormous amount of time and effort to produce this behemoth, and that most of that time is donated without remuneration by extremely busy people who lead active clinical lives and have abundant administrative responsibilities. The process of generating a syllabus, or an exam like the First Part, is therefore a function of the sleep it stole when it followed the examiners home on their late evenings and early mornings. In summary, if you don't like it, go try to make your own syllabus for basic sciences in critical care and see how far you get before you become ensnarled by questions like where the control of body water belongs (Applied cardiovascular physiology? Body fluids and electrolytes? Endocrinology?)  or how much does an intensivist really need to know about the definition of the term "systolic". 

Considering that to manually update over 600 pages of CICM Primary Exam content with new syllabus terms had taken over twelve hours, the author is glad that CICM have a syllabus revision cycle of something like six years, and looks to 2029 with a sense of exhausted dread, as surely by that stage Deranged Physiology will be even larger, and still without other contributing authors.