MRCEM Taken After Today No Longer Valid for FRCEM Final

Congratulations to the batch who passed their MRCEM OSCEs held in June 2018! You are the last batch who are eligible for FRCEM Final without sitting for SJP.

Beyond this, the FRCEM Intermediate Certificate (SAQ + SJP) becomes the standard criteria for all to be eligible for Final examinations.

There will continue to be a MRCEM OSCE for those interested in obtaining the title, but it is no longer a compulsory exam.

What does this mean for us? Well, PGMSS insists that we need to have MRCEM to register with them for eligibility into the FRCEM structured training programme, unless you somehow already have an active GMC Registration (then you only need Int Cert). This is possible if you were previously a UK medical student who converted your student registration to doctor. I am not sure if you can reactivate it now if you didn’t back then, so better ask the GMC and let me know so I can include it here.

Anyway, I think the OSCE will still be hosted regularly, at least in India, as it is necessary for GMC Registration. With the MTI programme still in place, Indian and Pakistani trainees still need to register with the GMC in order to do their attachment in UK, and for now, only MRCEM is recognised for that. It is unlikely that FRCEM Int Cert will be recognised for registration, as the GMC mandates a clinical skills exam component. Otherwise people will flock to do FRCEM instead of PLAB just to get into UK.

Oh yes, one last note on FRCEM Final eligibility, you must have minimum 7 years experience (including HO) to apply. I apologise if I mislead anyone into thinking you can become an EP within 6 years after medical school if you take this route.

MRCEM Postgraduate Diploma

After successful completion of FRCEM Primary, Intermediate SAQ and MRCEM OSCE, you will be informed within a month that your name has been submitted to the board for consideration of Membership by Examination. It may take 10-12 weeks for approval.

Once approved, you will be asked to pay the membership fees for that year (GBP200 for 2018) and you will then be formally recognised as a Member of the college. You may choose to receive the diploma by mail, or by attending their conferring ceremony held in November/December every year. If you choose to receive by mail, you will still be invited to the conferring ceremony, of course, so save your end-of-year leave!

In my case, I wanted the certificate earlier so they mailed it to me. They sent it rolled up in a nice plastic tube, so don’t worry about the post office folding it.

The Membership has to be renewed every year, and must be maintained if you plan for FRCEM Finals as a foreigner. Eligibility for FRCEM Finals is that you pass FRCEM Primary and Intermediate (SAQ+SJP), have 36 months experience after completion, AND be eligible for UK GMC Registration. In order to be eligible for GMC Registration, you must either have graduated from a UK medical institution, or passed PLAB, or hold a UK postgraduate diploma (ie MRCEM).

This is why most of us must go for MRCEM.

Taklimat FRCEM Parallel Pathway Programme in Malaysia – 2/6/2018

It’s official! The FRCEM parallel programme is in motion. A lot was announced and discussed at the briefing in Hospital Sungai Buloh today, but the bottomline is that MYCEP and RCEM have reached a partnership that will be formalised at EMAS.

1. As of June, Singapore will cease to be a centre for FRCEM Primary. Instead, Kuala Lumpur will host its first FRCEM Primary in December 2018. Subsequents exams will then be imported in stages, as early as March next year for Intermediate SAQ.

2. Those who have already acquired the full MRCEM award need to register themselves with the local Post Graduate Medical Specialist & Subspecialisation (PGMSS) to be recognised as an alternative pathway trainee. PGMSS will then send you a training manual and transfer you to a recognised training centre (TBA) to be supervised for at least 36 months. You will then be eligible for FRCEM Final exam (in UK, if they have not brought it into Malaysia by then). Pass the rotations and the FRCEM Final, gazette for 1-2 years and finally be registered to NSR as an Emergency Physician.

3. FRCEM obtained in Malaysia cannot be brought to the UK. In the UK, you need a CCT/CESR on top of your FRCEM to practice as an EP, which requires a minimum number of years spent in the NHS and a list of competencies verified by their consultants. Likewise, FRCEM obtained in UK cannot be brought back to Malaysia. You still need to be reviewed by the NSR, and may be placed into any rotations lacking.

4. The eligibility criteria for each FRCEM exam component remains the same as stated in RCEM website.

Will post more details later.

MRCEM is coming to Malaysia!

After months of silence about bringing MRCEM to Malaysia, it looks like this is really going to happen. This will mean lower costs and less time off needed to take the exam.

However, I don’t think it will be a true parallel pathway like MRCP or MRCPCH. It will probably be more similar to MRCS, where it becomes an entrance exam into the Masters in ED programme. The curriculum required to pass MRCEM is simply too basic compared to MMed or FRCEM Final, so it cannot possibly be considered a specialist qualification.

I also don’t think they will bring FRCEM Final into Malaysia because nowhere else in the world has, even though Singapore, Oman, and India have been hosting them for years. They would need to adapt the Critical Appraisal and QIP papers into the local system; they would need examiners familiar with the curriculum… in other words, actual FRCEM graduates. Last I checked, there are none in Malaysia.

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!

Overview of FRCEM/MRCEM for Malaysians (Edited for 2018)

Hello and welcome to my blog. I served a tertiary Emergency Department in Malaysia, and recently qualified for the Membership of Royal College of Emergency Medicine (MRCEM) by examination. Many people have asked me about the process, so I decided to write this blog to provide some guidance. My advise is based on the application process as of 2017, and may not reflect any updated changes in later years, so do check the official RCEM website (www.rcem.ac.uk) for confirmation.

For those unfamiliar, the MRCEM is a 3-part UK postgraduate exam for eligibility into higher specialty training in Emergency Medicine, similar to MRCP for Internal Medicine or MRCS for Surgery. As of 2018, the MRCEM is now a gateway into the new FRCEM parallel pathway for specialisation as an Emergency Physician (see here and here). Following MRCEM, you will then have to meet several criteria and be eligible to sit for the 4-part FRCEM Finals exam which will then enable you to be registered on the National Specialist Register.

The MRCEM may also be used to boost your CV when applying for the local Masters programme. In fact, it is a named extra component on the Master’s programme applicant scoresheet, gaining you more points for each part passed. Entry into the MMed for EM programme is becoming increasingly competitive each year (2017 ratio 3-4:1), and qualifying candidates often differ in scores by mere decimals, so that little extra may make a huge difference.

For HOs and district MOs, passing at least FRCEM Primary (previously known as Part A) will help you secure a place in emergency departments with specialists so that you can be properly trained and supported for Masters. Had I not taken the exam, I may be in Paediatrics now! (Nothing wrong with paeds, but I already had my mind set on EM since my undergraduate years).

The exam is also recognised for entry into emergency medicine training programmes in UK, Ireland and Singapore, but there are many more hurdles to overcome when applying for training overseas. Many have done it though, so it is not impossible.

As mentioned earlier, the MRCEM is a 3-part exam, specifically called FRCEM Primary, FRCEM Intermediate (SAQ and SJP), and MRCEM OSCE. They were previously called MCEM or MRCEM Parts A, B & C, but underwent major overhauls in the format and content over the last 3 years, so many reference books and question banks are still not reflective of the current exam style.

The FRCEM Primary is now a Single Best Answer MCQ paper on basic science. There are 180 questions to be answered over 3 hours. Questions are usually in the format of USMLE, where a clinical scenario is given, and you are asked a basic science question related to the scenario. For example:

A man sustained a deep knife wound across the cheek. Which of the following features of facial nerve injury would not be present?
A. Loss of forehead wrinkling
B. Drooping of the lip
C. Loss of taste to the anterior 2/3rd of the tongue
D. Ptosis
E. Loss of nasolabial fold

The FRCEM Intermediate now has 2 parts – Short Answer Question and Situational Judgement Paper, of which only the SAQ is required for the MRCEM. The SAQ comprises of 60 clinical scenarios with subquestions worth a total of 3 marks per case. Questions may be on clinical knowledge, practice guidelines, laws, or ethics. For example:

Picture shows a lateral foot X-ray with a fractured calcaneum.

This patient is a construction worker who fell from 2 stories and landed on his feet.
i) Describe the Boehler’s angle in this X-ray. What is the significance? [1]
ii) What other injuries would you look out for? List 4. [2]

You have just discharged a patient who had a seizure. You overhear that he intends to return to work as a bus driver.
i) According to the DVLA, how long must a person with a first seizure abstain from driving Group 2 vehicles? [1]
ii) According to the DVLA, how long must a person with recurrent seizures abstain from driving Group 2 vehicles? [1]
iii) If the patient does not heed your advise, what is your role in notifying the DVLA? [1]

Lastly, the MRCEM OSCE has 18 stations on various clinical, teaching, communication and ethical scenarios. Each station is 8 minutes long and scored according to a marksheet, examiner impression and patient impression.

After passing all 3 exams, you will be eligible for membership by examination, and will have your name submitted for approval, which may take up to 15 weeks. Once approved, you pay the membership fee, and you are now a title holder.

I will talk about each component in more detail in another post, so stay tuned!

I have not included the FRCEM Finals in my blog as I have yet to sit them myself. But stay tuned over the years.