Exams within IM residency

[Rome]

I understand that there are a few in-course exams that is mandatory for an IM resident to write. Would anyone be able to explain what these exams and when in your residency you write them. Thanks!

[ffp]

There are two types of exams: those required for licensing purposes, and those specific to your program.

For the licensing exams, most people do LMCC2 in fall of their PGY-2 year (this is standard for all residents, IM or other). It is basically an OSCE-style exam. Forget how many stations, but it deals with very common things running the spectrum from peds, O&G, acute management, communication, medicine, psych, surgery. It is a very basic, general exam, but I found that as an IM resident who hadn't looked at peds, surgery, O&G or psych for >1yr, I did have to review a bit. I think >95% of Canadian grads pass this without much difficulty.

At the end of your 4th year of residency (after you have started your subspecialty), you do your Royal College Licensing exams. This is what earns you the FRCP(C) and allows you to practice independently and bill! This is currently the bane of my existence as it is coming up in <1 month's time for me. It involves a MC exam (200 questions over 2 days), as well as an oral exam (OSCE-style, scenarios and physical exam). The oral takes place in Ottawa, so everyone has to travel there. Just looking through the old exams, it seems to test esoteria rather than common things. I usually do well on exams without much effort, but for this one, I am SCARED. It is also an EXPENSIVE exam ($600 to have your training assessed, $2750 to register for the exam, not to mention the cost of flying to Ottawa and staying there for 2 days).

As far as in-training exams go, I can only speak about U of S:

In first year, you do an "observed history and physical" exam in the fall. This is just to make sure the new R1s are all starting off at the same level. Basically, you go with an examiner to see a patient, and you do the history and physical just as though you were seeing a new consult in the ER. It's a bit artificial because in the ER you would also have collateral history from family, access to old charts, lab investigations, etc. You also would not do a COMPLETE physical... but whatever.

At the end of R1, you do an OSCE. This is a fairly simple exam which tests common scenarios seen by an R1 in internal medicine (DKA, PE, hypercalcemia, etc). By the end of your R1, you are so used to seeing and managing these things in real life that the exam is a breeze.

In R2 and R3, we have 2 oral exams/year. They are Royal College style, designed to prepare us for the big kahuna in 4th year. Basically, you go with 2 examiners and do 2 physical exam scenarios, 4 clinical scenarios, and usually an X-ray or ECG. Not too bad, but you can totally tank if you get a weird scenario. All in all, a very good learning experience, though.

In addition, we write the ACP in-training exam every fall. This is an exam written by all IM residents in North America. It is MC and a full day. It is designed to show you how you stack up against your peers overall, and in all of the different subspecialty areas (you get a percentile score). It's useful for identifying your areas of strength and weakness. ACP exam scores have also been correlated with scores on the Royal College exam. Apparently with my percentile, I have ZERO percent chance of failing the RC exam. somehow, this does not reassure me :(

At U of S, none of these exams are actually used for promotion purposes, but simply for your own education. Exams might be used to identify residents who are struggling, but you wouldn't be forced to repeat a year or do remedial work based on poor exam performance.

[Rome]

What is a pass on the Royal College Licensing exams? I am also curious to know what happens when someone fails this examination, is there a re-test or do you have to wait and write it again next year?

[ffp]

If you fail the RC exam (sadly, I know people who have, and this is what scares me because they are average residents and not terribly bad) then you are eligible to write it twice more before you need to have your training reassessed (and may have to do some additional training before you are eligible to write again). You have to re-write both parts - there is no such thing as passing the written and failing the oral or vice versa. Unfortunately this means paying the #%$ing fee yet again and waiting a whole year. It also means you can't practice. You can still work as a resident/fellow/house officer, but you can't practice independently and bill for your services. For me, it would be ok because I still have at least 2 years of fellowship left. Ideally, I will start doing locums as soon as I pass this bloody thing, but it isn't essential for me to make a living. I know someone who has failed it twice now, and is finished his ID fellowship. He can't work until he passes the exams, so he is doing a Master's and taking house officer shifts to pay the bills :(

There is no defined "pass" on the exam. Rather, I think you can automatically fail if you do something that would be unethical or endanger the life of the patient. Otherwise, I think they look at everyone's score as a whole, and compare how you did to the rest of the group before deciding "pass" or "fail". Everyone is expected to have a FITER (final in-training evaluation report) filled out by their program director. The FITER is basically a letter outlining your strengths/weaknesses as a resident. If you are "borderline" on your RC exam, they will read your FITER. If your FITER is glowingly wonderful, you will pass the exam. If it's average or worse, you will fail. If you're a clear-cut pass or fail, they don't bother reading the FITER.

I hope not to personally find out what happens if one fails this exam... but I'm not in one of my more optimistic moments :(

[Rome]

ffp, I feel awful about having asked my pass/fail questions, seeing how you are in a sad mood. From the sounds of things, you seem to be studying hard in preparation for this exam. I am sure you will do great!

[ffp]

hey, don't feel bad! It doesn't bother me that you asked those questions. I'm just stressed because compared to people in some other specialties, I am in a very intense fellowship (which I knew when I signed up for cardio). I'm doing 7 call/month, plus 2-3 house-officer shifts (self-inflicted), and although I have been on very light rotations since January, my days at work can still be long.

It seems like my friends in resp, heme, etc have been doing nothing but study this year, but I haven't had the time. I've always done well on exams without studying much, so I never developed efficient study habits. I figured this exam was "crammable" just like everything else, but looking at old questions, I've realized that they focus strongly on minutae, and things that one might not have seen or done during 4 years of residency... it's kinda scary.

The other scary thing is that in some cases, you can predict the people who will fail (ie. IMGs with poor command of English). Other cases are completely unexpected. The vast majority of people pass this exam on their first try. Lesser people than me have passed, but people who are the same or better than me have failed! I know two cases where absolute "superstars" just had a bad day and tanked the oral. I know two other cases where people who are average residents (not dangerous, but not brilliant either) failed it. One of them (the guy with the ID fellowship) was my senior resident when I was in PGY-1. It's weird, because now when he does cardio house-officer shifts, he has to review patients with ME and write, "discussed with Dr. ffp" at the bottom of his consults!

In reality, whatever the outcome, I think I'm ok with it. If you fail, you pick yourself up, dust yourself off and try again. At least I'll know exactly what to expect next year. If I pass, I plan to reward myself with a tropical vacation :D I also already have a locum as CTU attending (Me??? CTU attending??? SCARY!) lined up for this summer if I pass!

[mamboya]

Hi ffp,
Iam new to this forum and hopefully will be sitting for my IM RC exam next year. I was wondering if you have any study resources for this exam to share.
Any pointers or review courses for preparation of this exam

Thanks

[mamboya]

I have PM you my e.mail address already