FRCEM vs Masters in ED

I once said that the FRCEM/MRCEM is more similar to MRCS than MRCP, because it is mainly used to supplement your entry into the local Masters programme. But not anymore. With the introduction of the FRCEM Parallel Pathway, the FRCEM exams are now more similar to MRCP in that you can pick one or the other to become an emergency physician.

So how does that change the relationship between the two options? Not much, for now.

For those in the early stages of their EM career, the MRCEM exams still carry bonus marks towards your Masters application. It will also secure your place in an Emergency Department with a specialist, which is mandatory if you want to apply for Masters. Those two benefits alone justify attempting the exams if you can afford to. It will also keep you studying while you accrue the minimum number of SKTs (3 consecutive years) to qualify for Masters. After all, PIAEM, like FRCEM Primary, is a Basic Science exam, and everyone forgets all that BS once they stop studying, except BS lecturers. (note: pun intended, insults not.)

Eventually, you will reach the crossroad – Masters or FRCEM. What’s the difference? I would like to thank Dr Shaik Farid (USM EM Lecturer) for making this easy.

FRCEM vs M Med
Duration

The Masters programme is a 4-year programme assuming you pass everything without a hitch. To be eligible for Masters, you need at least 3 SKTs, so you would have done at least 2 years HO and almost 2 years MO before you qualify, making the minimum time to gazettement as EP 8 years. However, do note that Masters competition is tight and majority of successful applicants are at least UD48s (5 years MO). So, you’re looking at a 10-year journey.

The FRCEM pathway can begin from HO years, but you need at least 36 months of clinical experience (including HO) with minimum 6 months spent in ED before you can attempt the MRCEM OSCE. You can then register with the Postgraduate Parallel Pathway Unit and do structured rotations for 36 months before you qualify for FRCEM Finals. This makes the total around 6-7 years, assuming you pass everything in one seating.

Gazettement is longer for parallel pathway candidates, but you will still be paid as a specialist from day 1 of gazettement, so I didn’t include that difference in my calculations.
Cost

Most Masters candidates are sponsored, so the cost is minimal. However, you are bonded for 5-7 years, with a penalty of RM100-160k for breaching it or failing the programme.

FRCEM exams are wholly yours to pay for. On top of the exam fees, there will also be admin fees that have to be paid additionally for importing the exam. When the exams were held in India, each paper cost an additional RM1000. Assuming the same, and all 8 papers are imported, the total would be around RM24k. In case the exams have not been imported when you reach a particular stage, you’ll also need to factor in cost for overseas travel and accommodation. At present, there is no bond for the FRCEM Parallel Pathway, unless they successfully send you for the 1-year UK attachment. Then you will be bonded 3 years.
Curriculum

The Masters programme follows local practice that are familiar to us. You will spend 24 months rotating in various specialties and subspecialties, and another 24 months spent in the Emergency Department.

FRCEM follows UK practices, which differ more than you may think. One particular area of concern is the ethics, laws and administrative practices, which differ so astoundingly that you may resort to giving up those questions in the exam. There are also some significant differences in clinical practice like preference for Seldinger chest tubes over blunt dissection for pneumothorax, a lower threshold to discharge, use of clinical scoring systems uncommon in Malaysia, etc.

Rotations in FRCEM are 36 months, with 24 months spent in ED. However, UK candidates require minimum 6 months spent in each of Medicine, ICU, OT and Paeds EM. How that will be mapped out for us remains a mystery.
Assessments

The Masters programme has an entrance exam, 2 major exams (which has multiple papers each), and a thesis to assess your progress.

The FRCEM has 8 exams, and requires you to complete a quality improvement project for one component. Quality Improvement Projects (QIPs) are basically audits on clinical practice, where you evaluate current performance, suggest changes, and re-audit after a period of time. You will have a viva on it during your FRCEM Final.

An important point to stress here. FRCEM Finals have notoriously passed 0% of international candidates thus far, hence the need for that 1-year attachment in the UK. Whether that is sufficient remains to be seen. The good news is UK EDs are so shorthanded now there shouldn’t be much issue getting candidates in. They already have a transfer programme with India and Pakistan for EM trainees, so that shouldn’t be too difficult to arrange.
Conclusion

The Masters programme will remain the mainstream and steady path to specialisation for most in the near future. It is theoretically longer, but familiarity will ensure a smooth sailing through the programme if you keep your standards up.

FRCEM is the road less taken, and I anticipate many hiccups for the pioneer batches as they face various administrative blunders and curricular inadequacies. There are no past examples of successful FCEM/FRCEM candidates among the Malaysian EPs, so guidance will be speculative, especially surrounding the logbook and supervisor reports. The exam will be no easy feat either, although there are existing question banks and past papers.

My bet is that they will only bring the FRCEM Finals into Malaysia after there are several successful candidates who are willing to take up the role of trainers. To hasten the process, perhaps MYCEP can consider engaging some of the Malaysian FRCEM holders working in the UK to return.
Extra Stuff for Overachievers

This section is for the strange people who want to get both Masters and FRCEM.

Please note that the goal for both pathways is to make you eligible for NSR registration, so doing both is redundant.

The FRCEM title also does not grant you right to work as a specialist in any other country, even the UK and Ireland, because they have their own specialist register, and they sure aren’t going to approve a bloke who’s never stepped foot into their local hospital lobby before. You would likely be required to go through the whole 5-6 year training programme, only exempt from the exams. This is also provided you have not yet exceeded the age limit.

So, in the end, the title will serve as nothing more than a decorative post-nominal which cost RM24k to obtain and RM2500 per year to maintain.

If knowing so you still want to go for it anyway, the short answer is you can.

You would need to make the extra effort to fill in the logbook and supervisor reports necessary for FRCEM Finals eligibility. You would need to arrange your own time to sit for the exams, although you can always do that after you’ve cleared your Masters programme.

For those contemplating doing both simultaneously so you can hop onto whichever ship you complete first, I highly doubt that will be possible like in MRCPCH or MRCOG, since the tasks required are so different. A dissertation for Masters AND a QIP for FRCEM, along with all the rotations… I think you deserve an easier life. Also, you will still be inflicted your full penalty of RM100-160k for breaking the bond. So yeah, don’t try it.

That’s all. Will add anything extra I can think of later.

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.