Zen and the art of passing a fellowship exam

Todd Fraser on 02-08-2013

Sometimes a little self congratulations is not a crime.


Passing a fellowship exam is an enormous effort, something I think we fail to appreciate, nor celebrate, like we should.


I'm moved to write this by some of my communications with friends, colleagues and occasional acquiantances who are in the middle of preparing themselves for the CICM fellowship exam and the UK FICM final exam.  Some of them are going through tough times.


I somewhat bitterly recall the year I sat for my fellowship.  I was in a new city, a new job, no friends or family, a SR job for the first time, 2 young (very young) kids and the massive stress of working a full time job and studying for a hellish exam.  It was an incredibly taxing time, and I'm fortunate to have had the enduring support of my beautiful wife and my bosses at the time.  How we all made it through unscathed (or did we?) is beyond me.  


I remember vividly, through teary eyes, reading the college letter over and over and over, just making sure it really did say "Pass".  The overwhelming emotion was not elation, nor satisfaction, or even happiness.  It was relief.  Relief that it was all over.  Relief that I, we, did not face it again.


I recently had the opportunity to chat with another recent graduate, a colleague from Wellington, about this very topic.  We share a concern that there are many people striving for what we've achieved who may well be at breaking point.  Do we, as an industry, care enough about those senior trainees going through a significant life-stress?  Are we doing enough to support them?


I don't know, I suspect not, but right now, find your trainees, ask them how they are doing and offer them a hand.  I know I appreciated it when someone did that for me.



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Todd Fraser from Australia wrote 08-02-2013 12:23:02 pm
A friend of mine from Cairns sent me a list of life rules, some of which are relevant (thanks Sean) :

Alain de Botton's 'list for life'

1. Resilience: Keeping going even when things are looking dark.
2. Empathy: The capacity to connect imaginatively with the sufferings and unique experiences of another person.
3. Patience: We should grow calmer and more forgiving by being more realistic about how things actually happen.
4. Sacrifice: We won't ever manage to raise a family, love someone else or save the planet if we don't keep up with the art of sacrifice.
5. Politeness: Politeness is closely linked to tolerance, -the capacity to live alongside people whom one will never agree with, but at the same time, cannot avoid.
6. Humour: Like anger, humour springs from disappointment, but it is disappointment optimally channelled.
7. Self-awareness: To know oneself is to try not to blame others for one's troubles and moods; to have a sense of what's going on inside oneself, and what actually belongs to the world.
8. Forgiveness: It's recognising that living with others is not possible without excusing errors.
9. Hope: Pessimism is not necessarily deep, nor optimism shallow.
10. Confidence: Confidence is not arrogance - rather, it is based on a constant awareness of how short life is and how little we will ultimately lose from risking everything.

Sean McManus from Australia wrote 08-02-2013 03:23:11 pm
Hi Todd,
Great post, really important issue that is difficult for many to discuss, as we pride ourselves on our coping skills. Emotional well being is often way down the list of priorities in the type A personalities attracted to work in the Critical Care arena.

In 2012 I had to do a year as an SR in another city in pursuit of FCICM. Sadly, I was asked to move 2 weeks earlier than planned as one of their registrars committed suicide around Xmas 2011.

Even worse, there was no formal debrief for the rest of the junior staff. When I raised this with the consultants there was no real appreciation of how serious it was.

I then struggled personally with the demands of 2012, luckily one of the new consultants provided mentor style support, without which I would not have endured a tough year away from my home town with my family split up.

Mentoring is an essential part of most successful enterprises, we need a little more of it in Medicine.


Kaz from Australia wrote 08-10-2013 12:03:53 pm
Thanks Todd for bringing this up. This is a seriously important issue, and like Sean I have been confronted with the harmful effects.

I struggled my way through the exam process and split with my partner at the time. We never saw each other and we just drifted apart. It was a very taxing time. At least one of my study buddies confessed to feeling suicidal during the process.

Is it the colleges' responsibility to provide support for trainees? I don't know if it is but it would be nice if they did. Is this the case in other countries or other specialties? I should find out what the college offers for my own trainees...

Thanks again

Zaf wrote 08-11-2013 09:54:04 pm
Thanks Todd for this post.

I am one of those trainees currently in the midst of studying for the fellowship - ACEM, rather than CICM. I must say it feels like there is always that gray cloud over my head. Every time I want to go out with the kids to the play ground I am thinking "I could be studying"... every night I go to sleep I am thinking "maybe I could stay up a bit later and do one more question"... every time I go out with friends for a coffee I am thinking "I should be at home studying"... it really is a burden.

What is particularly hard is not necessarily the exam itself, but more the juggling of every other aspect of life at the same time - your duties as a father, spouse, work collegue, sibling. I can fully understand how others can feel suicidal or depressed during these times.

I agree with Sean that having a Mentor is a really helpful way of "sharing the burden". Another thing that is helpful is having a study group to share the pain together with. You really got to be in the right frame of mind when you sit.

I recently listened to this useful podcast called - "Getting it right the first time - Exam Preparation" by sport psychologist Patsy Tremayne found at

Some extremely useful and interesting tips - studying in the mornings, studying in chunks, nutrition, appropriate use of tone and timbre during vivas...

I feel like my life is on hold until this exam is over, that life will "begin" again once this hoop has been jumped through... looking forward to the day it is all over...

Ziad from australia wrote 08-12-2013 06:47:58 am
great post
being at the step 1 of the fellowship exam trip makes it helpful to see what others went through to get there ,i sometimes ask my self why do i do it ?i can easily switch to a job with a license to print money yet ,i still go to work enjoying getting paid less than the mechanic who is about to fix my car this morning ,i still enjoy helping patients in real strive ,i still enjoy the monumental challenge of facing a patient on the cusps of heaven then try to help them stay on earth ( or hell in other words )
just at the start of preparing for my fellowship exam ,i know it will be quite tough times for me & my family ,yet i know i will enjoy it

Todd Fraser from Australia wrote 08-12-2013 09:42:18 am
Thanks all for taking the time to comment

Its clearly an important issue, and many of you are describing similar experiences to me. I'm pretty sure that means that most of us feel the same way.

I have two questions - for those going through it now, what resources would you like to see available? How can we help you? How could the process be better? What are the main issues you need to overcome?

For those of you who are now past it, and are in positions where you supervise / mentor / care for trainees doing the exam, what processes and procedures, what resources do you have in place to help?

What should the role of the college be in this process?


wrote 08-13-2013 01:02:37 pm
Hi Todd,

Thank you for raising this, and in such an eloquent manner. I had meant to get back to you on it after the ASM but as per usual you were far more proactive than I. In fact, I meant to write on this particular issue after I sat my exam in 2008! Like you, there was little joy in it. It had been an extremely stressful year and I felt both relieved, but also a bit angry, at the the process I had been through.

Intensive care asks much of its trainees. The stressors you described are very common.

Trainees are a mobile population which often means not only the stress of moving location and workplaces but also away from usual supports.

It is also a time of life where there is often additional relationship pressure. For the single trainee, there is no opportunity to develop new relationships which are sought for companionship, security and support. For those in new relationships, time is demanded, but not easily available. And for those in established relationships, often new families are starting or the pressure of postponement of such life goals builds and the increasing demands for support take their toll. Every moment seems to have high opportunity cost, yet there does not seem an end in sight.

Within the workplace, we work in a high stress environment. Often highly traumatic situations are dealt with for the first time, and alone. We are frequently asked to deal with death and dying, we see the full emotional spectrum, and the variety which draws us all to the specialty adds academic and cognitive demands. The pressure of responsibility as we make high pressure decisions increases with training.

Trainees work highly unsociable hours. Rotating shift rosters confuse body clocks and fatigue builds as the trainee tries to fit in as much as possible to keep up.

Add onto this the FCICM exam, an exit exam which prides itself on its degree of difficulty, which at its most recent sitting had a pass rate of 35%, and the obstacles can certainly seem overwhelming.

What are the costs of such a training scheme?

I'm sure all of us have seen them:

failed exams and lost time
broken marriages or relationships
loss of friendships
alcohol or drug abuse
mood disorders
loss of self-identity, hobbies and the feeling of being uni-dimensional
burnout, cynicism and emotional apathy
loss of child-bearing opportunities
in extreme cases, suicide and death.

Some walk away to find friendlier environments, but many of us have fallen in love with Intensive Care and continue this rite of passage. We are a strange bunch who like to be surrounded by stress and such demands get normalised. We are surrounded by suffering via patients, families and fellow colleagues, such that our own difficulties are often marginalised or seem unimportant.

I have had the good fortune to get to the other side. As a new consultant, I hope I can reassure that life is much better. There are a whole new bunch of stressors to deal with but that exquisite pressure I felt as a trainee is no longer omnipresent. I have reestablished hobbies, been able to better prioritise family, friends and my long-suffering and enormously supportive wife, and feel more in control of my work patterns. I even have a routine now that I am free of the registrar shift work. I love my job and the clouds have largely lifted.

However, I suffered through some very dark times to get here and were it not for my wife Maria (who put her own medical training on hold, partly to raise our 3 children and partly to avoid the double-specialist training nightmare) and plenty of luck along the way, I feel that I could have had deeper wounds instead of the minor scars that I bear.

I think that the system is setting a decent proportion up for failure on some level. We are able to quantify the exam failures, but have little data for the other negative consequences mentioned above.

My impression is that the prevailing attitude is that this is a rite of passage with limited consequences which will pass in time and should just be tolerated. An attitude of "If it was ok for me, and I'm ok, then you will be too". One must prove one’s worth to be considered ready for the job.

There is no doubt that hard work and sacrifice are required in order to do the job. But is it okay, in a profession which is about looking after the wellbeing of people, to recognise these stressors and risks and not act to try to reduce them? Particularly when we strive so hard for improvement in all other areas of practice?

So what can be done to help trainee welfare?

Recognition of the problem. This will require a culture change within Intensive Care. Blogs like this are a start but the dialogue needs to be broad and open. Data may need to be collected to confirm the size and nature of the problem and to convince those that can only be convinced by scientific evidence.
Senior support. Mentoring has already been mentioned and is crucial to help navigate the training scheme. Sometimes just as a listening post, sometimes to share wisdom, sometimes to redirect, sometimes to intervene. SOTs have a vital role in not only ticking college boxes, but in supporting trainees through their training including a recognition of welfare issues.
Collegial support and friendship. Study groups have been mentioned and are invaluable as a source of shared knowledge, experience and strength through adversity. Face to face groups are great, but online support through study groups/blogs/discussions is a growing area to utilise as necessary. As a trainee, your colleagues are likely the people you see most of and who have the best understanding of your current context so seeking and providing support is really useful.
Personal attention to health and stress. Know yourself well (and listen to those who know you well). Figure out a strategy for debrief and to unwind. Don’t be afraid to say no or ask for help. Know your priorities and be prepared to advocate for them. If you’re not very assertive, try to find allies who are. Have a GP and look after your relationships outside of work - they will be the ones who pick up the pieces if it all goes wrong. Decide which aspects of your life you are not willing to compromise on, and find a way of ringfencing them; if you don’t protect them, they can easily be eroded away.

And where does the college fit in?

Welfare SIG +/- officers. ANZCA has a Welfare SIG (special interest group) to discuss matters of member welfare among like-minded individuals. Some departments have welfare officers. Should this be more a part of CICM?
Trainee representation. Your trainee rep is your conduit to the college. Choose them wisely and ensure that they are supported to speak up about trainee stresses and concerns.
Part 2 exam. This is a whole different topic. However, I wonder whether the exam is doing trainees justice in its quest to turn out better and better intensivists. Is it appropriate for an exit exam to have a 35% pass rate? Does that mean a problem with the training or with the exam? I wonder whether a different exam process mightn’t significantly reduce the stress on senior trainees.

Anyway, I’m interested in others’ views. Sorry about the length of this response Todd but you have hit a trigger point. And thanks again for bringing it up. Your final advice is perhaps the easiest and best to institute.

Look after one another, we’re all in it together.


Sean McManus from Australia wrote 08-20-2013 05:45:48 pm
Great post Chris, agree with all the points you have made. I have seen both sides and it definitely gets easier once the training is done. As a FANZCA I have had many quiet chats with Trainees in the hope they will cope with the stresses of specialist anaesthesia training

I now find myself on the other side dreading sitting an exam with a 35% pass rate, and I already have a consultant job! The only thing on the line is my pride, so I can only imagine the pressure on those who need to pass to get on with their career

Agree that CICM needs to look at the hard stats with respect to the Fellowship Exam. One would think that appropriate selection and training of bright, motivated doctors would lead to a pass rate of at least 50%

Your comment about Trainee representation is timely, yesterday CICM contacted me to tell me I am now on the Trainee Committee, so I might follow this issue up in that forum. Being a little older and armed with ANZCA College experience may help highlighting this issue.


Mahesh from Australia wrote 11-27-2013 06:42:51 pm
I came across this whilst looking up the discussion on the TTM paper.

Thank you Chris for so eloquently expressing what many of us are going through. I say this as someone who is at the beginning of the fellowship exam journey (probably sitting in 2015). It's nice to know that there are people who care.




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