ARE YOU THINKING IN THE CORRECT DIRECTION?

There is a real and appreciable difference between examination emergency medicine and “real life”. Often in the ED senior doctors are handed an ECG and asked to interpret it. This is analogous to the “old” VAQ exam and the “describe and interpret” type questions. The only way to approach the ECG was with a systematic drill, and work through it logically. But, the new exam is different.

Take question 2 from the most recent paper....

To paraphrase Doctor Who, time in exams is less than linear and much more “wibbly-wobbly".

Candidates are given a generic scenario of a 65 year old with palpitations, followed by an ECG. It is entirely predictable that there will be a question on the ECG and what it shows. At this point candidates can look at the ECG, decide what it shows, make a note of the major abnormalities and then proceed to answer the question. There’s nothing really wrong with this, but it will take a *lot* of time (remembering there are only 6 minutes allotted per question).

So open your mind for a moment and allow the fellowshipexam.com team to propose something radical:

Skip the ECG and move straight on to the first question.

Here at fellowshipexam.com we would contend that this is not only possible, but a cognitive approach which will maximize exam completion speed and therefore marks accrued. To paraphrase Doctor Who, time in exams is less than linear and much more “wibbly-wobbly”.

Take a look at the actual question:

“List four (4) of the ECG abnormalities you can see to support the diagnosis of Ventricular Tachycardia.”

Astute examination candidates can immediately infer several two important points:

1. the ECG shows a diagnosis of ventricular tachycardia
2. there will be multiple abnormalities that support this diagnosis.
   

So theoretically it should be possible for candidates who have strong knowledge of the ECG features of VT to write an answer without the ECG, because based on the two inferences above the ECG MUST SHOW VENTRICULAR TACHYCARDIA.

What are the major features of VT?

Depending on which source you read they read something like:

1. regular broad complexes (QRS >120ms) with a tachycardia (HR >100)
2. a “northwest axis”
3. concordance in the chest leads
4. AV dissociation
5. fusion beats
6. capture beats

If we had to describe an ECG of VT without seeing it we’d probably write an answer in that order.

Interestingly, when we look at the ECG provided in the exam question
(https://www.acem.org.au/getmedia/0384ec35-94b5-4787-b71d-55de6c7b369c/Item-Writing-Handbookv2-compressed2.pdf.aspx), it’s quite easy to see:

• a regular broad complex tachycardia
• extreme left axis deviation, bordering on “northwest”
• a fusion beat
• a capture beat
• significant concordance in the chest leads

This means that if we’d indeed done the question blind (without seeing the ECG) we probably would have scored very close to maximum marks. Now we're not suggesting that you do the question blind at all, just that you consider altering the direction of your cognitive approach on occasion.

Working backwards from the diagnosis rather than forwards from the clinical diagnosis is a very useful tool to have in the toolbox, especially in an exam where mere lost minutes make a difference to passing or failing. Again, it’s a tool best learned with practice, and something you won’t develop from textbooks alone. At fellowshipexam.com we’ve got 26 weeks of SAQs for our students to cut their teeth on, so that when the big day comes they are as efficient and well prepared as possible. Check out our website for more information!