CICM Part II Preparation guide

In their preparation,  candidates for the Fellowship Exam may wish to consider the following issues.

They don't want any more fellows.

That is probably the most important concept to internalise when preparing for this thing. Unfortunately, the ICU environment has a strongly pyramidal structure, and in order to function there must always be more junior trainees than consultants. Ergo, not all trainees can expect to become consultants. Ergo, there is no incentive to produce new consultants, given that at present there are few unstaffed positions.

They aren't threatened by you.

The exam is fair, and the examiners are not trying to fail you. Certainly the likes of you are no competition for them. In any case, under the present conditions, their jobs are untouchable - particularly in the public health system. As a "staff specialist",  one is like a barnacle: practically impossible to dislodge from the hull of the ICU. You would have to sexually assault the nurse unit manager or do something equivalently criminal to stand a chance of being kicked out of such a position. Ergo, the exam is fair. It would actually take more effort to make it unfair, and that would be wasted effort. The worst thing that could come from a fair exam, as far as the existing cadre are concerned, is an excess of unemployable fellows, whining about their job prospects.

Preparation for the written

The past papers are your curriculum

There is a number of reasons as to why one should use the past papers as the main form of written exam preparation for the CICM Part II. These reasons include:

  • The official curriculum is poor in quality, insofar as it does not specify which exact competencies are going to be tested, or how. The exam papers offer exactly this information.
  • The textbooks, they are out of date as soon as they leave the printing press. Oh's Manual particularly is dangerous, as it is widely beleived to be "the Bible of Australian Intensive Care". However, it contains numerous things which will not be examined, and it fails to include numerous things which are vital to the candidates. Concentrating one's reading on Oh's Manual will therefore result in a poor performance. Certain selections from Oh's are important, and these are identified in the SAQ discussions wherever they come up (classically, the contents of some of the "blue boxes" from Oh's fits this description). Otherwise, one may safely omit reading Oh's. This recommendation is supported by a small case series (n= 4).
  • SAQs are repeated, and repeated SAQs should be viewed as free marks. 

Thus, one can safely limit one's preparation to past exam papers. The best way to prepare is to grab a hold of these papers and start working though the SAQs, writing your own "model answers" to them - initially in an open-book sort of way, and subsequently under exam conditions. 

The past papers are not "model answers".

Because that would be insane. Looking at many of them, one must naturally come to either the conclusion that nobody could ever write so little and pass; or the conclusion that nobody could ever be expected to write so much. One of the readers (Dr Rob Paul), in a grip of what I can only describe as rage mixed with despair, observed that the college answer to Question 21 from the second paper of 2019 contains 1805 characters (284 words). That's not even one of the longer ones. Dr Paul rightly pointed out that this adds up to 28.4 words or 180.5 characters per minute, which exceeds even the speed record of police interviewers, and in fact exceeds the range of what is physiologically possible for the human wrist apparatus. To quote Hardcastle & Matthews (1991),

"In undisputed police interview records, the highest speeds observed fell in the range 120–155 cpm; in the controlled tests the highest speeds were in the range 150–160 cpm. It is concluded that in real interview suations, speeds of 150–190 cpm are unlikely to be attained and speeds above 190 cpm cannot be attained."

In short, one should not view the college examiners' comments as model answers. Trainees are encouraged to write their own model answers, under open-book conditions, and then carry this trauma into their postgraduate careers, when they might have a chance to finally design some better quality Part II questions and answers as the next cohort of examiners. 

Concentrate on structure

Highly competent candidates with vast knowledge have sabotaged themselves by leaving their detailed answers unstructured and disorganised. Conversely, candidates with below-average theoretical knowledge have managed to scrape through because they had been able to demonstrate a level of organisation, or a systematic approach to problems. Structure is therefore very important. It also makes the SAQs easier to mark. Suggested structured approaches to common questions are presented elsewere.

Concentrate on timing

Highly competent candidates with vast knowledge have also sabotaged themselves by trying to write everything they know about a topic for every SAQ. These people then went on to run out of time, missing out on several SAQs. Each SAQ is generally worth ten minutes of your time, but one should get used to completing an SAQ in eight minutes or less. Timed "exam conditions" trials were essential to the author's preparation.

Viva preparation

Generally, this area enjoys a reasonably good pass rate, much as the written paper does. This makes sense because much of the theoretical work which is required for the written paper is also required for the vivas, and if one has managed to pass the written component one typically possesses enough knowledge to get through the vivas.

Merely spouting key phrases is not enough.

Some discussion is expected. The exam is marked in what can be described as "the Delaney Grid", named after Anthony Delaney who has been instrumental in developing it. Essentially, the marking criteria of each question (or viva) has a list of concepts. Each concept has a marking breakdown, ranging from zero (not mentioned at all) though the 2-3s (mentioned briefly, or with errors) to 6-7 (discussed in detail, and accurately) and 9-10 (weepingly beautiful answer). This is how you are marked. A person who attempts to answer a viva in the verbal equivalent of point-form will only score the 2-3s (mentioned briefly) for each mentioned concept.

Dress code

The college usually sends out a thing where they recommend you "look professional and feel comfortable". For some reason, each time 90% of the candidate population intepret this as "wear a suit and tie". This is in fact not a bad idea. Professional attire is an inexpensive and effective method of cynically manupulating the subconscious perception of your competence by the examiners. Sure, taken individually they are each immune to such chicanery, but the process of examining forty candidates should hopefully dull their insight and makes them susceptible to these sorts of psychological parlor tricks.

Hot case preparation

Don't put it off.

The hot cases are weighed as 40% of the total exam mark. That is more than the written paper. Each hot case is 20%; which means that every minute spent examining the patient is equivalent to two SAQs. Remember this. Start practicing for the hot cases immediately as you decide to sit the exam. You will need to develop a certain polish by the time the exam rolls around. There is an entire population of trainees (the author himself among them) who neglected case presentations until it was way too late (i.e. until after the written results became available). Don't be like those people. 

Don't do anything weird.

Do you normally wear a full three-piece suit to do your rounds? Do you engage in bed sheet origami, folding it weirdly around the patients' groin? Do you normally carry a briefcase full of physicianly equipment? Hell no. So, don't do it at the hot cases. These days even ties are discouraged, and the college recommend either short sleeved shirts or sleeves rolled up. Generally, try to dress like you're going into a family conference where some piece of horribly tragic news is going to be unveiled. Don't be absurd. Of course you don't perform direct ophthalmoscopy on every patient; so don't tell the examiners that you would do this. Don't try to test the olfactory nerves in the comatose cardiac arrest survivor.

Don't annoy the examiners

Remember, you are one in a fairly large group of people, and the examiners have been examining since the break of dawn - they are cranky and hungry. Give them no additional reason to hate you. Don't ask too many questions- it irritates them. Especially avoid taking the first five minutes of your hot case asking them questions about the ventilation and dialysis settings. Avoid gibberish: as you do your examination, it is ok to point out salient findings as you go (particularly as you demonstrate neurological signs) but do not rant continuously. Rapid pressured speech commenting on everything during the process of examination gives the impression of poor confidence; it is the mark of an amateur. If you are more comfortable with silence, perform the examination in a quietly businesslike manner, saving your comments for the end.

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Hardcastle, R. A., and C. J. Matthews. "Speed of writing." Journal of the Forensic Science Society 31.1 (1991): 21-29.