Rotations Starting Soon!

This is a bit late to be called news, but Dr Sabariah, head of Emergency Medicine Services in Malaysia, recently emailed all ED MOs who have registered with PGMSS to update their exam status, as she is in the process of arranging rotations for the Parallel Pathway.

Especially those of you who have completed all parts of MRCEM, do collect and fill up the PGMSS forms as it is now mandatory for your rotations to be recognised as part of training. Otherwise, you will not be able to register with NSR.

Do also consider joining the FRCEM/MRCEM Malaysia Support Group on Facebook, as there are loads of information, study resources and support available there now.

Official Signing at EMAS

Sorry for the poor quality as I was seated quite a distance away and had to 3x zoom with my smartphone…

Anyway, here we are! The official partnership signing between MYCEP and RCEM to kickstart the parallel pathway. I look forward to see all phases of MRCEM and FRCEM slowly rolled into our country, followed by FRCEM certified EPs over the next 5 years.

MRCEM Award Ceremony in UK

While there hasn’t been an official invitation or notice, the RCEM has strongly indicated here that the annual award ceremony for new FRCEM/MRCEM diploma recipients will be held on 6 December 2018 in Central London.

So save your leaves and book your tickets for a UK trip! It’s Christmas season and Europe will certainly look beautiful that time of year!

Edit (25/7/2018): They have just confirmed the ceremony date and venue here. Those eligible can expect an invitation anytime soon!

MRCEM OSCE

Similar to many Membership exams, the 3rd exam is a clinical OSCE. Unlike other Memberships, this is relatively easier to pass with success rates consistently around 60%.

There are 18 exam stations and 2 rest stations, each lasting 8 minutes. Tasks may be any of history taking, physical examination, management, counseling patients, teaching colleagues, communication with patients or colleagues, and procedures. Often multiple tasks are involved. Topics are as broad as for FRCEM Intermediate SAQ but more predictable.

India actually holds the OSCE on separate dates from the UK. Usually, India holds it in June/Dec while UK holds it in Apr/Oct, so check carefully.

Registering for the Exam

This is the only exam out of the 3 that you should book as soon as possible. While not always, the OSCE is often overbooked, and they will only inform you 2-3 weeks before the exam that they couldn’t fit you in. The registration window opens 2 months before the exam.

As of 2019, it will become necessary for you to have passed the FRCEM Intermediate SAQ to be eligible for the OSCE.

Again, you will need to upload your Alternative Certificate of Foundation Competencies and your translated Full Registration cert. You can use the same ones you used before. There is again an additional ~RM1000 admin charge for taking the exam in India.

You will again need a supporting Supervisor (EP/Consultant) whom the college will communicate with to determine your eligibility for the exam. The queries for this is apparently longer than for Intermediate so do keep bugging your boss to check their mail and get it done ASAP. Remember, Often Overbooked.

Preparations

The OSCE is highly schematic and scored against a marksheet. The MRCEM Part C: 125 OSCEs book by Somani will cover most of the stations and the sample marksheets provided are pretty accurate.

The rest is up to practice. Grab a dedicated partner! Brush up your English and showmanship! No clinical skill is foreign to the Emergency Physician! I was asked to do a full ear examination, including rinne/weber and otoscopy. I have heard of people getting fundoscopy examination as well. Practice!

Exam Day(s)

The exam is held over a few days, with 2 sessions each day. You will only sit one of those sessions, and you’re free to go. You will be assigned your session about 2-3weeks before the exam.

I took mine in Chennai, so I can only speak from my experience there. It is again held at the Apollo Hospital in Annanbakam, waaaay out of the city centre, so arrange your accommodation and transport accordingly.

I am unsure about attire rules, as I did see people attending in scrubs. I would still advise to dress in formal attire, though. You may bring your stethoscope, but other equipment will be provided.

Once at the hospital, the reception will guide you to the gathering area at the back where you will be quarantined with other candidates. You will then be lead to the meeting rooms upstairs where they have multiple rooms set up as osce stations.

What surprised me most was that there are no clocks in the stations, so you have to rely entirely on your own estimation for your 8 minutes. There is also no 1 minute bell; you will only hear a bell to signal the end of the station. I did not manage to complete many of my stations.

Once the exam is over, if you are in the morning session, you will be escorted to a quarantine area for 1-2 hours. Once the afternoon candidates have all begun their session, you will then be allowed out to collect your belongings and exit the hospital.

After the Exam

You will receive your results by e-mail a month later. They will also provide you a performance feedback another month later, or earlier for those who fail.

If you have passed FRCEM Primary and Intermediate SAQ as well, you will also be informed that you have been recommended to the RCEM board for MRCEM award. I will cover details on this in another post.

Thanks for reading!

FRCEM Intermediate SAQ

Formerly known as MRCEM Part B, the FRCEM Intermediate SAQ is now a written exam comprising 60 scenarios, each with question stems totaling up to 3 marks. It is, in my opinion, the most difficult of the 3 MRCEM exams, because it tests on a wide range of care that would normally be delegated to primary teams in Malaysia, a lot of OT/Anaesthesia knowledge that majority of ED MOs never got to experience, and a lot of administrative, legal or ethical frameworks that only UK doctors would be familiar with.

Applicants may notice that there is something called FRCEM Intermediate Certificate, for which you have to sit for an additional exam called the Situational Judgement Paper (SJP). It is an ethics exam where you rank best choice of action for each scenario. For now, it can only be taken in the UK and is not relevant to foreginers as it is not required for the purpose of obtaining MRCEM. You can try it if you want, though.

Application

There are a lot more pre-requisites for this exam than the FRCEM Primary. First, you must have passed the FRCEM Primary. Second, you must have completed housemanship. Third, you must have an emergency physician whom you have worked with for at least 3 months support you for this exam.

Again, you apply through the RCEM website. The exam is usually held in March and September, but application windows open about 3 months before. Check the dates here.

You’ll need to supply the following documents before the closing date:

– MMC full registration certificate (original and translated)

– Alternative Certificate of Foundation Competencies (completed and signed by an emergency physician who has worked with you for at least 3 months)

The ACFC is a checklist detailing all the knowledge, skill, communication, ethics and professional competencies expected from a UK Foundation Officer (their version of HO) who would be eligible to sit for this exam. It is available here and should be dated no less than 3 years from the exam date. It is 8-10 pages long with tiny wordings requiring signatures every row. Please give your EP plenty of time and roti canai to go through it. More than one EP can sign it, but there must be a main supervisor whom the RCEM will contact. Make sure your EP puts down an e-mail address they actually check!

You will be asked to choose an exam centre. The nearest is India, which has many centres, but the cheapest flights are usually to Chennai or Hyderabad. Regardless of where you choose, there will be an admin fee of RM1000+ to be paid to the exam centre on top of the exam fee of £305. If you take the exam in UK, you do not have to pay an admin fee, but travel costs are significantly higher.

After that, there will be a period of waiting as the RCEM checks your documents and contacts your supervisor. Make sure your main EP provides an active email address that is regularly checked.

Once your application is approved, you will be asked to pay the exam centre admin fee by foreign telegraphic transfer, and both RCEM and your exam centre will issue you the confirmation letters.

Your headache isn’t over yet.

India Travel Visa

Unfortunately, you cannot willy-nilly fly to India and just walk through customs to get a chop. You must apply for a visa before you travel, either eVisa or Regular Visa. Both applications can be accessed here. (Be wary of scam sites that look very similar.)

E-visa can be done fully online, and thus has the advantage of convenience and speed. The process takes only 3 days, and they sometimes do it overnight or over the weekend. There is also a separate counter for eVisa at the airport, bypassing the much longer regular visa queue. However, it is only valid for 3 months from date of approval, so don’t apply too early. Once used, the visa remains valid for 60 days, and you can enter India a 2nd time within that period, which is usually not long enough to sit for MRCEM OSCE. You are limited to only two applications per year, then you have to apply for regular visa.

Regular visa requires several visits to the Indian embassy in KL or Penang for submission and collection. The good thing is it grants you a slightly longer validity period for about the same price, so you can use the same visa to sit for OSCE. To apply for the regular visa, you again visit the visa website and download the application form for regular visa. Complete that form and compile your documents, then drop them over at your nearest Indian Embassy. They’re quite fast, so you can expect to hear back within the promised number of working days.

Don’t forget to bring a copy of your visa when you fly!

Chennai

I took my FRCEM SAQ in Chennai, so I am only able to discuss this.

The exam hall is usually in the nursing college next to the Ambattur Road Apollo Hospital. The exterior is hot and humid like Malaysia, but the exam hall is as cold as Singapore’s NUS exam hall, so again, gear up with a jacket and heat pads.

Logistics will probably be your biggest challenge. The exam centre is far from the city centre, about an hour away, and there are no lodgings near it. The nearest that I could find was Oyo Rooms Preetham Nivas, which is still 15-30 minutes drive away from the exam centre.

Speaking of transport, taxis and took-tooks are notorious rip-offs, scammers and double-crossers, and they often don’t know the way. Fortunately, Uber and Ola are reasonable options there, but you’ll need mobile data, which I could not find there. I usually use an uber to get to the exam centre, then bite my lips as I pay double to get back with a took-took. The airport is about 30-40 minutes from the city centre, so your best option is to catch a taxi. Government taxis are the safest because you pay a fixed sum up front, but they will still harass you for extra pay when they get you to your destination. Sorry, need to back track, before you even get onto the taxi, the driver’s assistant will demand tips for leading you to the taxi. Prepare LOTS of 50-rupee bills; you will be doing this a lot, everywhere.

Food in Chennai is priced equivalently or cheaper for the Malaysian pockets, and tastes familiar since they’re largely Tamil dishes. I never got traveler’s diarrhoea either, so the people who wrote the chapters on traveller’s diseases probably just have paper guts (haha!). Try their kopi tarik; really nice and costs <RM1 a cup.

FRCEM Intermediate SAQ

Finally, we reach the part you went through all that trouble for. Let me refresh your memory. 180 minutes to complete 60 scenarios, each with variable number of questions requiring short answers that will total up to 3 marks. Scenarios may call for clinical knowledge, procedural knowledge, basic science knowledge, ethics, laws, admin and protocol, etc.

The possible topics are very very broad. Going in without much intel since I was again among the guinea pig batch as they fine tuned the exams, I resorted to studying the clinical components for other college exams ie MRCP, MRCS, MRCOG, FRCA, etc. Fortunately, by now there have been many precedences and I think one can easily search for the many available MRCEM Telegram study groups to obtain the past questions.

My advise is to be very textbook. I know Malaysian practice tends towards inserting size 28-32Fr chest tubes for spontaneous pneumothoraces, but the UK guidelines does needle aspiration first and then proceeds to size 14-16Fr chest tubes if needle aspiration fails.

The few ethics and legal questions will also trip Malaysian candidates. If you are confident in your clinical knowledge then these won’t be enough to pull you under the fail line. But if you want the extra confidence, feel free to visit the GMC website on Good Medical Practice, and read on the Mental Health Act 2005 and some driving license guidelines on the DVLA website.

Results

Like the other papers, your results will be out in 3-4 weeks from the exam day. Look up the Results page in the RCEM website. Look for your candidate number and beside that will be your result – either Pass or Fail. Another 2-4 weeks later, you will receive feedback on your performance, in comparison with your cohort.

Good luck!

My Experience with FRCEM Primary

The FRCEM Primary is the first MRCEM exam, and is making its way to become the commonest external paper held by ED MOs in Malaysia, especially Masters applicants. It is a basic science exam similar to PIAEM, although many have remarked that the FRCEM Primary is more difficult due to its wider scope of topics. It is quite common to see PIAEM applicants taking FRCEM Primary as both exams are held about 1 month apart.

The exam is held twice a year, usually June and December. The nearest exam centre to us is Kuala Lumpur.

My first advice for you is to plan ahead and don’t miss key dates.

Application
You must first register an account on the RCEM website. Most of the details required are straightforward, and it’s free.

Next, you wait for the opening date for application for the FRCEM Primary, which is available here and updated regularly. Be aware that the application date usually closes 4 months before the actual exam date.

All you need for registration is £310.00 and upload a copy of your current MMC registration (provisional or full). Our MMC cert is in Malay, so candidates have to submit both the original and a translated copy. Translation has to be done by a credible authority, which means:

– High Court
– Malaysian Translator’s Association (MTA/PPM)
– Institut Penterjemahan dan Buku Malaysia (ITPM).

Commissioner of Oath or independent translators are not accepted, unless they are certified by any of the 3 authorities mentioned. Translating the certificate takes about a week and costs ~RM50.

During the application, you will be asked to select your preferred exam centre. They force you to provide a first and second choice, but historically everyone has always gotten their first choice. The exam centre is in KL; exact venue I do not know; candidates do update me please.

After you apply, the RCEM should update you within a month of your application if they need further documents. Make sure you look out for that because they can reject your application if you don’t respond and you will have to wait for the next sitting 6 months later. If all is well, they will send you a confirmation letter and your exam placement a month before the exam date.

Exam Content and Preparation

The exam format consists of 180 Single Best Answer MCQs, covering:

  • 60 questions on Anatomy
  • 60 questions on Physiology
  • 60 questions on Pharmacology, Microbiology, Pathology, and Statistics

The (not very specific) curriculum can be found here (pg 7). Official sample questions are available here. You can definitely get a better picture from question banks and the Revision Notes book.

Questions usually begin with clinical context then zoom in on a relevant basic science question from it. For example:

This patient presented with progressively severe shortness of breath following a week of fever and cough. You treat him for severe pneumonia and, anticipating respiratory failure, have intubated him. He weighs 70kg. What initial tidal volume will you set for this patient?
A. 70ml
B. 140ml
C. 250ml
D. 420ml
E. 700ml

You are treating a patient for myocardial infarction in cardiogenic shock and have started him on noradrenaline. Which of the following best represents the adrenoreceptor activity of noradrenaline?
A. Only α effects
B. α = β effects
C. α > β effects
D. β > α effects
E. Only β effects

Disclaimer: These are simulations in the same style, but not the actual questions that appeared in my exam.

The pass mark is not fixed, but is based on the Angoff method, which means ‘what a panel of examiners feel minimally qualified candidates should be able to achieve’. I suggest a safety line of >65% to be considered a pass. Usually around 33% of candidates pass this exam. When I sat it in 2016, the pass mark was 54% and around 35% of candidates passed. But subsequent batches needed >60% to pass and had about the same pass rate.

Personally, I felt the level of knowledge required is a bit more than undergraduate basic science exams, and with less time. The nearest comparison I can think of is USMLE Step 1, except Step 1 has way more depth in biochemistry and pathology, but less in anatomy.

My practice questions were:

  • Get Through MCEM Part A (still in the old true/false format)
  • FRCEM Exam Prep
  • FRCEM Success
  • MRCP/MRCS Part 1 practice questions that I scavenged off my MOs (MRCS is very good for anatomy, MRCP is good for the rest)

My reference texts were:

  • General: Revision Notes for MRCEM Part A (latest version says FRCEM Primary), First Aid for USMLE Step 1 (whichever year is fine)
  • Anatomy: Clinical Anatomy by Harold Ellis
  • Physiology: Constanzo Physiology + Guyton & Hall for cardio, respi, renal
  • Pharmacology: Rang & Dale
  • Pathology: Robbins Basic
  • Microbiology: Made Ridiculously Simple

If it looks like I read a lot, it’s because I had 2 years of HO to prepare, and I only used them for details I didn’t understand as I did the practice questions. Those on a tighter schedule should focus on anatomy and physiology, then use Revision Notes to cover the rest.

I did the practice questions and read the revision notes, anatomy, and physio texts at least twice. That still didn’t prepare me for the tricky or trivia questions, but I saved a lot of time on straightforward ‘know or don’t know’ questions.

Clutch time started around 1 month before the exam, during which I just did 3-hour exam simulations or studied Revision Notes. Fortunately, I was floating at the time, and my department was considerate enough that they didn’t give me much responsibilities except that I show up to punch in and help around when it’s really busy.

The Exam Day

As of June 2018, the exam will no longer be held in Singapore. Instead, Kuala Lumpur will be the new SEA centre for Primary from December 2018. Would appreciate if candidates can update me on this.

After the Exam

The RCEM will release the results on their website and to your email about 3-4 weeks after the exam date. They will first inform you if you have passed or failed. About a month later, they will send you feedback and the breakdown of your performance.

Good luck!