FRCEM Primary: a survivor’s story

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Last December, I’m pleased to say I sat and passed the first membership exam for Emergency Medicine in the UK; the FRCEM Primary.

Whilst I was preparing for this exam, I searched pretty much the whole internet for advice (notable posts I’ll link below). So I figured it may be useful to others if I add my own experience too. Obviously, take the thoughts below for what it is; personal experience. You may benefit from a different approach, but for me at least, I’m happy with my score. For transparency (since I’m giving advice on how to pass an exam) I scored 77% – far from exceptional, but a comfortable pass.

The way I prepared for this exam may be overkill for some people, but I think it more or less guarantees a pass.


📝 A bit about the exam:

Anyone who’s reading this is already in a very specific demographic to know what the exam is. But for completeness, the Primary is the first in a series of exams on the journey toward full membership of the Royal College of Emergency Medicine. It is a written exam, that tests basic sciences, with limited clinical focus. Think back to your first years of medical school, pre-clinical.

Unlike the first examination for anaesthetics, you can choose to sit this exam at any time from foundation year 1. I did mine a few months after finishing FY2, and I’d recommend doing it as early as you can (within reason) to free you up for core/specialty training years and the Intermediate exam (you must pass the Primary and Intermediate in the first 3 years of EM training).

At time of writing, the exam is computer-based (due to COVID). You can either sit this in an exam centre (like the driving test ones) or at home (which sounds much more stressful with invigilation via a webcam). I had a great experience in a small Pearson Vue centre and would recommend that versus home (stress of connectivity issues and stories of disqualification for adjusting a jumper etc).

It costs £310.

🔗 Structure

There are 180 questions to be completed in 3 hours; that’s one minute per question.

  • Anatomy: 60 questions
  • Physiology: 60 questions
  • Pharmacology: 27 questions
  • Microbiology: 18 questions
  • Pathology: 9 questions
  • Evidence based medicine: 6 questions

As you can see, the lion’s share is in anatomy and physiology, with reducing emphasis further down.

Prioritise anatomy and physiology. I spent the vast, vast bulk of my time on these. As for EBM (stats and whatnot), I probably spent only a few hours studying this stuff. For anatomy, upper and lower limb anatomy seem to take a big emphasis. Physiology, everything seems up for grabs really (less so the haematology side of things).

👨‍💻 How hard is it?

The pass rate (% of those who passed the exam) can be variable each year. The 2018 June pass rate was 45.5%, whereas 2019 June was 58%. Generally, a ball-park of just over half fail/pass rate is about right historically though. Average exam scores for candidates are in the 55-60% range.

My Clinical Supervisor told me that this was, in its own way, one of the hardest exams of the RCEM membership exams. Mainly because of the sheer volume to learn, the more abstract nature of the material (lung volume loops, cardiac action potentials etc), and the relative lack of direct clinical correlation. These are also sentiments that I have heard from other senior colleagues, and knowing this is somewhat reassuring when revision-blues starts to bite hard.

In terms of knowledge level needed, the disparity between topics can be quite large. For example, you are expected to know the following aspects of the radial nerve.

  • Nerve roots/trunks/divisions/cords/ contributing to radial nerve
  • Cutaneous branches
    • inferior lateral cutaneous nerve
    • posterior cutaneous nerve arm
    • posterior cutaneous nerve forearm
    • superficial branch radial n.
  • Motor branches:
    • Radial nerve –> muscles supplied
    • Deep branch radial nerve –> muscles supplied
    • Superficial branch radial nerve –> muscles supplied
    • Posterior interosseous branch –> muscles supplied
  • Clinical manifestation of lesions to different areas of the radial nerve

But regarding the colon circulation, you only need to know primarily about the inferior and superior mesenteric arteries., and not all the other sub-branches. This makes sense from an EM perspective, as we are unlikely to be fiddling with somebody’s left colonic artery, but likely to be dealing with upper limb trauma on a regular basis.

🗓 Preparation Time

Traditionally, it’s thought of as a difficult exam, although people have different experiences in preparing from it. The shortest prep time I’ve been personally told of is 3 weeks (this is serious outlier territory), and the longest is 2 years. I spent about 8-10 months, with the last 3 months being more focused and intensive.

I was working a full-time EM rota during the revision period for me. Toward the final 1-2 months I was studying up to 6-8 hours per day on my days off, as well as trying to get about an hour or so done during work days (apart from 12 hour shifts – that was a write off).

Cleverer people notwithstanding, as others echo, I’d suggest:

  • Minimum 3 months revision
  • Cumulatively looking at around minimum 100+ hours of revision (I was more likely around 200-300 I think – the usual terror of failure drove me)

📚 Study Approach

There is some good consensus on the study approach for this exam.

  1. Use the RCEM Basic Sciences Curriculum
  2. High volumes of question bank practice
  3. Do not cover-to-cover read textbooks

My approach:

I’ve seen people say ‘this is your bible for FRCEM’ – hyperbole aside, the Basic Sciences Curriculum was central to the structure for my revision. I used the curriculum as my map, and followed it cover-to-cover, making notes as I went along. I used evernote for this, and just kept adding chapters and notebooks for each topic. I wanted to take the time to read up on and learn the topics, and used the resources (listed below) to do this.

I initially started with most of my focus on covering big topics (like cardiac cycle, control of respiration, brachial plexus etc) and tried to actually learn them. As time went on, and I felt like I was progressing nicely through the curriculum, I started to switch toward more question bank based learning. Eventually, my time was about 90/10 questions to rote learning. I’d make very specific flashcards about questions that I got wrong, and set them aside specifically. Whereas questions that highlighted a general deficit in knowledge would prompt me to go away and study that topic in more depth, adding to my notes in general.

I kept my notes digital, but preferred physical flashcards as I could just thumb through them when I was idling around the house or doing other things.

Saying that, on the whole I didn’t try to squeeze in questions during work or other in-between times. I found the quality of learning pretty poor if I tried to do this. I mainly relied on blocking out times to actually sit down and go through things. I was very lucky because my wife pretty much accepted that I would mainly ‘exist’ during the final 2-3 months of preparation, and I became a part of the furniture at the kitchen table with headphones and flashcards as my primary (depressing) companions.

In the last month of revision, I would focus heavily on practice exams. I got to the stage where I could get through a 180 question exam in about 2 hours, which gave me a lot of confidence in not running out of time for the actual thing. I probably did about 10+ practice exams. This also demonstrated that time under tension (just volume) cultivated better pattern recognition. So when I saw a question about foot eversion, my mind immediately thought “superficial + deep fibular nerve, fibularis brevis, fibularis longus, fibularis tertius”. Obviously I still made a lot of mistakes, but the connections improved in speed and accuracy over time.

Decision to commit:
I believe this exam is one of attrition. If I can pass, so can you.

The content itself is not necessarily difficult, but there is a lot of it. As medics, this stuff has been our bread and butter during medical school – brute-force memorising biological concepts and being tested on them via different questioning styles.

If you decide to go for the exam, then go for it.

This means making sure you can give it the time and headspace that it requires. A lot of the material is such that inconsistent revision will degrade the knowledge before sitting the exam (think of the mnemonics used to remember cranial foramina + related structures, cavernous sinus structures, or layers and contents of the neck). Much of this stuff isn’t cognitively sticky, and so you need to be able to keep it on the boil in the lead up to the exam to maximise your result.

Rapid Approach:

ONE approach that can certainly work, is just ploughing through question banks. This will actually be a possible strategy to pass the exam, and has definitely worked for people. This strategy has a number of important points:

  • I know people who have passed dong this, and the time/mental energy can be significantly less than the approach I have outlined above.
  • However, markedly increased chance of failure – question bank practice only enables surface level learning. Grasping concepts through deeper study allows multiple styles and angles of questioning to be tackled.
  • This content forms the foundations for your leaning and practice as a clinician – sure you can speed through it, but I’d argue that actually taking the time to learn will pay off in the long run.
  • Saying all that, if you’re pushed for time and need to get this in the bag asap, then the high-volume question-bank approach can be considered.

Stick to the curriculum

The difficulty with this exam is both its breadth and its scope. There is a lot to learn, but also a lot not to learn. It is vital to use the Basic Sciences Curriculum so that you don’t go down blind alleys of physiology, for example. The fields themselves are uncapped in depth, but the exam only asks for very specific knowledge. These topics have a tendency of dragging us down wikipedia/pubmed rabbit holes, and you can waste a lot of time if you don’t check whether the curriculum actually needs you to learn it. For example, you don’t need to learn the branches of the subclavian artery, but you do need to know the rectus sheath inside and out.

Just have the curriculum PDF open in another window at all times and cross-reference what you are learning. I systematically just worked through the entire curriculum from page 1 to the end. Its dry, interminably long, and miserable when its taken 2 days to work through one page, but it is what it is.

🖥 Question Banks

Regarding question banks, I tried most of them, my experience below (in order of preference)

  1. FRCEM Success: nice analytics, comparison with peers, very reflective of the actual exam content. Definitely recommend.
  2. FRCEM Tutor: similar to above. Good explanations too. I used these first two banks heavily, and completed both almost twice. Definitely recommend.
  3. FRCEM Exam Prep: did not find this to be as reflective of the actual exam. Some questions very far off the Basic Sciences curriculum map. I found the content quite a bit harder, and user interface not as good. Wouldn’t particularly recommend.
  4. BMJ Onexamination: did not find this to be particularly in-line with the curriculum in my experience. Expensive, and very limited number of questions. Wouldn’t recommend.

📖 Textbooks and other resources

There are a few textbooks out there for this exam, and even more for all the content it covers.

Generically, there were a number of revision sources:

  • Bromley Online Revision – 100% recommend. £16/month for teaching from an emergency medicine consultant and educator that is tailored specifically to the FRCEM Primary. It doesn’t cover everything, but will get you most of the way there.
  • RCEM Learning – practice papers here are a good way to gauge how you are doing, as they will be most representative of the exam.
  • Medical school notes – yup, some of this stuff came out again.
  • Youtube – really is invaluable.

Anatomy:

  • Teach Me Anatomy – the absolute mainstay of my anatomy revision
  • Youtube – no specific channels, but very useful to search
  • Some apps e.g. Human Anatomy Atlas – just being able to manipulate a 3D model around helped get the Transpyloric plane and other things into my mind

Physiology

Other advice for the Primary:
Don’t just listen to me; a few other people’s experiences of the Primary:

My notes:
I’m personally not a massive fan of using other people’s notes, but below are my own evernote revision notes for the Primary. It may be helpful to get a sense of the content of revision, at the very least. Warning: they aren’t the most organised/prettiest, and there are gaps. But I used these for my own revision.

Anatomy
Upper limb
Lower limb
Abdomen
Thorax
Neurology
Ear/eye
Face/head/neck

Physiology
Basic cell physiology
Cardiac
Respiratory
Gastrointestinal
Haematology
Renal

Other
Microbiology
Pathology
Pharmacology

💪Smash it

If you’d like to chat about any of this just send me an email and I’d be very happy to help in any way I can. Otherwise, I hope this helps and best of luck.

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