CICM Final Exam

The CICM final exam consists of a:

Timing

  • Read
    • Note eligibility requirements
    • Dates
    • Discuss with recent supplicants what is involved
  • Discuss
    • Mentors and supervisors
      • Am I ready?
      • When should I sit?
    • Partner, family, and friends
      Understand:
      • What is involved
      • The degree of sacrifice required
  • Assess
    • Is this an appropriate time?
      • There is never a perfect time
      • It will always be disruptive
      • Some times will be less-bad than others
  • Commit
    • Outsource what you can
    • Drop balls
      Many other professional and personal commitments have to be shelved until the exam is behind you.
    • Don’t equivocate
      Avoid dragging it out.

Written Exam

As with the primary examination, a structured answer format:

  • Provides a scaffolding to hang ideas off and prompt your memory
    • ↑ The chance you will deliver a complete answer
  • Buys you thinking time
    Your mind can think of content whilst you subconsciously outline the structure on the page.
  • ↓ Stress
  • Is less painful to read, and therefore more favourable to mark

Glossary of Terms

These verbs detail the expectations for the answer:

Re-read the question half-way through your answer - make sure you are answering the question that is asked.

  • Critically evaluate
    Evaluate the evidence available relating to a topic.

  • Outline
    Provide a summary of the important points.
    • Breadth > depth

  • List
    Provide a list.

  • Compare and contrast
    Provide a description of similarities and differences. You may tabulate your answer.
    • Provide a description of similarities and differences, not just a list
    • Detail the significance of these differences

If the question says you may tabulate your answer, you should tabulate your answer.

  • Assessment
    Generic term that implies determining an underlying diagnosis, encompassing; history, clinical examination, and relevant investigations.
    • History
    • Examination
    • Investigations
    • Prioritised differential diagnosis
    • Indicators of severity

  • Management
    Generic term that implies determining an overall management plan, encompassing; resuscitation, definitive treatment, initial and ongoing monitoring with supportive treatment.
    • Principles
    • Treatment Priorities
    • Resuscitation
      ABC approach. Comment on team coordination.
    • Specific therapy
      • Pharmacological
      • Procedural
      • Physical
    • Supportive care
    • Disposition

  • Discuss
    Explain the underlying key principles. Where appropriate, this may include controversies and/or advantages and disadvantages.
    • Depth > breadth
    • Controversies
    • Pros and Cons

  • Explain
    Make plain, interpret, account for.
    • Reference to underlying theory and rationale
    • Contextualised to the clinical scenario

Answer Templates

Structures for specific question formats:

  • Adverse outcome
    • Manage the patient
      • Resuscitation
      • Prevent further harm
    • Administrative
      • Patient and relatives
        No fault apology and open disclosure.
      • Staff
      • Department
        e.g. QI, M&M.
      • Document
  • Critically evaluate
    • Rationale
      Importance of the issue, e.g.
      • Prevalence of disease
      • Pathophysiology
      • Unique features of the therapy
    • Advantages of the intervention
    • Disadvantages of the intervention
    • Evidence
      • Pros and cons of trials
      • Limitations of trials
      • Special situations
    • Own practice
  • Toxin
    • Resuscitation
    • Risk assessment
    • Supportive Care
    • Investigations
    • Decontamination
    • Enhanced Elimination
    • Antidotes
    • Disposition

Oral Exam

Viva

The oral section aims to assess whether you are ready to matriculate from training and assume the mantle of consultant. This is far more a question of mindset than of knowledge. Therefore:

  • Embody the consultant
    • Decide the type of consultant you want to be
    • Be that person
    • Have (or fake) confidence
  • Engage with the consultant examiner as a respected equal
  • Immerse yourself in the scenario
  • Take some time to think of an answer
    But not too much.
  • Be authentic
  • Discuss balance of risks without waffling
  • If you are unsure of a course of action, then describe your rationale
  • Have some prepared statements phrases
    • “In addition to my usual anaesthetic assessment…”
    • Know what to say if you don’t know what to do

Pitfalls:

  • Attitude
    • Non-consultant like
    • Indecisive
      Using ‘could’ not ‘would.’
    • Inflexible
      • Refusing to be lead
    • Waffling
    • Too many lists
    • Does not answer question
  • Knowledge
    • Insufficient
    • Long checklists do not demonstrate understanding
    • Inaccurate
    • Not recognising knowledge gaps
      Demonstrates lack of safety.
  • Safety
    • Inappropriate drug doses
    • Does not know how to manage a crisis
    • Lacks insight
    • Refuses to accept guidance

Complete the CICM Communication Course prior to the exam; the communication viva scenario generally mirrors the course scenarios.

Hot Case

The hot case is the only part of the exam that assesses a candidate at the bedside. Hot cases are:

  • Challenging
  • Artificial
    The scenario is clearly unrealistic - suspend your disbelief.
  • Incompletely correlated with clinical skill
    Hot case performance does not equal clinical performance, however hot case practice ↑ hot case performance.
  • Routinely performed poorly
    • 60-70% of candidates pass
    • 30% of candidates pass both cases
  • Fundamentally a vibe check
    This is a test of “are you ready to be left in charge of the unit.” It is not a test of your ability to detect some arcane diagnosis.

The case itself consists of several stages:

The end-of-bed-o-gram and orbit provide the majority of useful clinical information, do not neglect them. Touching the patient is expected to occur at some point however, usually by the 2-3 minute mark.

My impression is that the most important stage of the hot case is the presentation - a good presentation can redeem a mediocre exam, but a good response to questioning can redeem neither.

  • Clinical question
    Brief stem with incomplete information, and a clinical question.
  • Reading time
    2 minutes. Decide:
    • What potential clinical problems may this patient have?
    • What part of the examination should be focused on?
    • Likely follow-up questions
  • Entrance
    • Lights
    • Gel hands
    • Introduce yourself:
      • To the patient
      • To the nurse
    • Ask about relevant position restrictions and languages barriers
  • End-of-bed-o-gram
    Stand at the foot of the bed and identify key room equipment.
  • Orbit
    Circle the bed space to identify:
    • Infusions
      • Nutrition
    • Monitor
      Ask for fevers.
    • Ventilation
      Ask about:
      • Sputum
      • Ventilator settings, if unfamiliar
    • Catheters and drains
      Ask for:
      • Urine output
      • Drain output
  • Clinical examination
    • Begin with adequate exposure
    • Structured approach
    • Can ask key, targeted, relevant questions
      Must be balanced.
      • Too many unnecessary or boilerplate questions suggest a lack of direction or thought
      • Too few questions means key information may not be provided
  • Intermission
    Brief period during which:
    • PPE is doffed
    • Hand hygiene occurs
    • The clock is stopped
    • You can collate your thoughts and prepare the presentation
  • Presentation
    3-5 minute presentation that should be concise, comprehensive, and rapidly delivered. This should:
    • Open with a brief, 1-2 sentence introduction that provides an overview of the clinical scenario
      This is your opportunity to demonstrate that you have identified the major issues.
    • Answer the question
      This should occur even if the answer is not clear - a precise answer will often be contingent on the availability and interpretation of ancillary information, which you do not have access to.
    • Provide a rationale for the answer
      Signposted, systematic description of the justifications for that answer.
    • Outline any caveats
      Signposted, systematic list of any concerns that may impact your decision, and how you plan to investigate them.
    • Finish with a list of relevant positive and negative findings from the clinical examination
  • Further questioning

Yes

No

End-of-bed-o-gram

Orbit

GCS

Decide:
Detailed
Neurological
Exam?

Detailed Neurological Exam

Targeted System Exam

Detailed Systems Exam

Targeted Neurological Exam

The hot case is like a tennis match in that the only part of the game that you can control is the serve - these are the examination and the opening of the presentation. Maximise this time.

References

  1. Hoffman, K. How the Hot Case Works. Intensive. 2021.