The Devil's in the details.

In the fellowshipexam.com blog a few weeks ago we mentioned the importance of structure in your exam answers. Funnily enough, how you put down your answer is almost as important as what you write down. Part of preparing for the big day is thinking about how and more importantly *why* you write what you write.

"The exam has rules and like any rules they should be used to maximal advantage..."

Let’s use our list of therapeutic goals for massive transfusion as an example. In our earlier blog we wrote that in answer to a question asking for 6 therapeutic endpoints for massive transfusion we would answer:

1. Normalization of haemodynamics (SBP >90, HR 100)
2. Capillary refill time approaching 2 seconds
3. Urine output >0.5ml/kg.hr
4. Lactate clearance of 50%/resolution of metabolic acidosis
5. Maintenance of normal haemostatics (INR as close to 1 as possible, normal TEG profile if available)
6. A normal clinical state, particularly normal mentation.

There are two important points to notice about the list above.

The first is that we have grouped some similar items together (1). Arguably systolic blood pressure and heart rate could be listed as two separate endpoints for the question asked. However ACEM has stated where 6 answers are requested only the first 6 answers will be marked. Putting down related items individually runs the risk of preventing later answers scoring when the examiner reads your paper, especially if there is only one mark available for these items. A sensible way around this pitfall is to group similar items together as we have done in (1).

Because we have bracketed the items together using the phrase “normalization of haemodynamics” we ensure that they must be considered together as one item (ie not read separately as the first two items on your paper). However, if there are two marks allocated for the two items, it’s highly likely we will score the two marks: after all, our answer irrefutably contains the correct information.

Essentially “bracketing” your answer this way where such an option is available ensures you maximize the information you have put in your answer within the rules of the examination. Think seven answers for the price of six. Therefore your examiner has every chance to score you well. Remember the exam has rules and like any rules they should be used to maximal advantage.

The second thing to notice is the level of detail provided in our answer. Compare the list above to a different answer with similar content:

1. Normal vitals
2. Normal capillary refill time
3. Urine output 40ml
4. Normal lactate
5. Normal coagulation
6. Normal level of consciousness.

It’s important to notice that although the content is the same, the answer we would submit is much more detailed (for the use of not very many more words). It’s possible that the less detailed answer would score the same marks but in our opinion an answer like this is all a bit too vague.

Examiners are entitled to have every expectation that candidate answers will provide detail consistent with the practice as a specialist emergency physician. A “urine output 40ml” answer is appropriate for some patients, but not all. A urine output >0.5ml/kg.hr is undeniably correct. "Normal" remains an unquantifiable term (and therefore one very difficult to mark well).

Careful preparation and practice lend an eye to such detail. It’s  a habit worth getting in to. If you pay attention in your preparation you can take away the ambiguity from your answers. Spending time as you practice thinking about the HOW and WHY of your answer, and not just the WHAT, is likely to pay dividends and help you prove you’re ready for that FACEM.