When getting your fellowship is like trying to catch a fly with chopsticks

I have had a lot of people contacting me after failing one of the many hurdles towards their ACEM Fellowship.  They are understandably devastated and disillusioned often having failed something for the first time in their life.  They struggle to get back on the study wagon and they question their clinical ability back at work having been told they are not worthy.  Each time they fail they doubt more and more that they even know what the examiners are expecting.  They feel a real disconnect between a system that is willing to put them in charge of people’s lives as an advanced trainee and a college that won’t give them this final stripe so that they can move onto the next phase of their life.  Their and their families’ lives are on hold waiting for the next sitting and the pressure to either win or give up the fight is enormous.

So this post is for all of you on that journey having the pleasure of facing another sitting of the fellowship exam and I am going to borrow from Mr Miyagi a man of great wisdom to guide you on your way.

Either Exam-yes or Exam-no but You Exam-guess so then you get *SQUISH*

The first step is to commit to the goal.  Think of the path to the exam like a road.  There are two sides – the left which is the quick one but it is rough, the right is longer but easier.  If you are doing the exam again you have to commit to it…and your family have to commit to it and all the hours of study and emotional turmoil and highs and lows that go along with it. You have decided you are doing the next sitting so you are “walk left side – safe”.  If you can’t whole heartedly commit to it for the 6-9 month lead up then you should defer and do it when you can and when you are ready to commit.  You are deciding to “walk right side – safe”.  To try and do everything and walk down the middle according to Mr Miyagi that just means you will be “Squished…like a grape”.  We don’t want you squished like a grape….

Wax on Wax off

Now that you have committed to your goal you have to do the hard yards.  You are going to need to go through the motions of rattling off the lists of 5 causes of petechiae, the pro’s and con’s of investigations for aortic dissection, the calculations for delta gap  for your written exam a billion times – You are doing “wax on wax off” breathe in through the nose out through the mouth so it is automatic.  You are going to have spent so many hours practicing your difficult airway algorithms, your ALS pathways, your resus scenarios, your teaching approaches so that they are all a muscle memory – “sand the floor, paint the fence Daniel-san”.

The exam is stressful, you need to be able to do these things no matter whether you are so anxious that you can’t remember your own name.  You need to able to do it even if you have made an enormous fool of yourself in the last station and you have to fight the urge to go home.  When it comes down to the exam you need these basics to be pouring out of you automatically so that if you find yourself in a brain freeze or freak out phase you can still get through the stations.  The examiners need to see that no matter what gets thrown at you as an emergency physician when you get your ticket and the buck stops with you that you can do it under any conditions.  This is real life…When you are a FACEM you have shifts when you have just got handover with 26 unsorted patients in the department, 3 complaints and half your shift off sick.  You still need to be able to ignore the chaos and conflicting demands and prioritise the management of the rapidly deteriorating child with a head injury AND keep your cool when the retrieval service starts by answering your call for an urgent retrieval by asking you “What is the patient’s address…”,…just saying.

Left, right, up, down, side, side, breathe in, breathe out and no scare fish

Once you have the many millions of details in your brain and at your finger tips and you can shoot them out at short notice and lightning speed it is time to polish your technique.

For the written exam that means your writing both legibility and your clarity- less so your language these days with the smaller volume of the answers required but there is still refinement that can take your answers from a long waffling sentence filling all the lines to the key points with outcomes and aims that distinguishes a borderline from a shining star consultant answer.

For the clinical exam that means your communication.  The OSCE is all about communication and all of us have things that we can improve in our clinical interactions. Some of us are too quiet, some too noisy, some say too much, too little.  Some of us are hard to understand, some of us are quick to anger (I am guilty of this for sure…).  All of these things need to stay at home (or possibly be saved for the football field where the worst that happens is you get sent off).  You have to present your self as calm, clear, concise, respectful and confident.  We all need to continuously work on our communication skills and get feedback on how it is received and improve as we go. Right now you need to get good feedback on how you communicate and whether this may be holding back your exam success.

If you are finding this is a real weakness then now is the time to work on it.  If you don’t then you may as well not sit as it is not going to get any easier when you are stressed out in the exam room  And you are gong to need to practice LOTS! You can’t change your inherent communication style with one or two feedback sessions.  If your feedback has been that you really have a problem with this then this is going to have to be your new way of communicating – at least in professional situations if not at the local store…

You must “look in the eyes – Daniel-san” or you won’t see what is coming to you whilst you go through the motions of running through your stations.  You get very good feedback from even the most hardened examiner if you watch their body language.

And above all you mustn’t scare the fish – the fellowship exam is not a place for you to test out new ideas or bring forward controversial new treatments without qualification.  Once you have the FACEM belt you can use your evidenced based knowledge to challenge established practices and improve patient care in a balanced way.  But do not introduce this in your exam…you will well scare the fish and that’s not a good thing.

It’s OK to lose to opponent it is not OK to lose to fear

When the day of the exam looms you have to enter that ring with your head high.  You cannot be shaking in your boots clawing your way into the room while your mind is screaming “flee flee”.  You have done the hard yards, the fence is painted, the floors are sanded, the cars are shiny it is time to step in and show them what you are made of.  You must not let fear get the better or you. If you do you may as well walk away now.

If that means that you spend some of the precious minutes in the lead up to the exam working out how you manage your fears then that is time well spent.

Managing fears is not easy…but there are things you can do to make it easier.  Fear affects your mind and your physiology and as doctors we should be clever enough to mange each of these things separately.

Your heart is racing, you can’t breathe, you are sweating, your mind is spinning.  Your physiology is taking over and it needs to be manged.  Once the physiology becomes unmanageable no amount of self talk will over come it.  You need to stop, you need to breathe, you need to focus and stop thinking about what is stressing you out.  You focus on what you can do.  You can stand there, you can  breathe in and out, you can look up and down, you can clench your hands and release.  You can do a lot of things and the most important thing you need to do is calm down.  Until you calm down you won’t be able to get through the task at hand.

Mastering your mind has to happen ahead of time.  You need to master this before you are staring down the entrance to the exam room. I know you don’t want to dedicate one second to anything other than your books, your job and the tiny amount of family time between now and the exam but if you are going to get through you may have to prioritise some of these things…

  1. Accept that you will feel anxious.  Own the emotion. Of course you are anxious – your life, your family’s future at least in the short term is hinging on your performance.  You have spent so much of your life on this and you have let the achievement of this goal define you.  You need to acknowledge the anxious emotion, recognise it when it arrives and have a game plan for letting it go.  It does not help you – it helps you when you are facing a lion but not when you have to calmly go in and write a paper or negotiate a difficult interaction.  Say hello to anxiety, package in it’s box and let it go away to come back when the lion, or the crocodile or shark is after you…not now. And if this is easier said than done then get some help with this as it will not be helpful in the exam room.
  2. Normalise it.  You are not the only one out there that is feeling scared.  There is nothing bad about you because of this feeling.  Believe me many of your colleagues are struggling with feelings of anxiousness and inadequacy entering that room.  It doesn’t matter that you are feeling it – just what you do with it.
  3. Name what the fear is and make a plan.  Is it the fear of humiliation of failure with your colleagues, is it a career issue – is this pass required for you to work your next position, is it a financial fear – have you over committed and do you need the raise to meet your commitments.  Whatever it is then try and work a strategy so that those things are not so important.  May sound easier said than done but it is possible and will make an enormous impact on your anxiety
  4. Expose and repeat.  If there is something that always makes you anxious (like entering the exam room or having someone watching and timing you or running the resus with all looking at you) then do it…. then do it again…. and again and again.  I often look at the guys that catch the big waves and I think what have they got that I don’t have – and it is water time – pure and simple.  They weren’t born braver, they have just numbed themselves to the fear.  You need to do the same.  
  5. Imagine yourself achieving your goal. You are ready.  You have put yourself forward, you have done the work, you are as ready as you will be by the day.  You need to believe this or you may as well go home.  You committed, you waxed on, waxed off.  Now you are in the ring.  You owe it to yourself to not let your fear beat you. Imagine yourself nailing the station.  See yourself in your minds eye achieving this. Then go in and do it.

As Mr Miyagi says “your best karate is still inside you, now is time to let it out“.

Karate – head, Karate – heart, Karate never belt

The last thing you need to do to finally get through this exam is actually not care about the ticket.  If all you care about is passing the exam then you are doing this for the wrong reasons and you probably will keep failing.  You have to become a FACEM in your head, a FACEM in your heart and then you will pass the exam. Being a doctor who performs at consultant level and cares for his or her patients with the knowledge and skill of a consultant is the pinnacle – not the FACEM label

The FACEM  tick is just a tick. It is not the most important thing.  As Mr Miyagi says ” a belt means no need rope to hold up pants”.

You don’t need the FACEM tick if you are performing like a consultant.  If you are treating your patients with exemplary care, you are managing your teams and your colleagues with professionalism and you are teaching your juniors who will be the next wave of specialists then you don’t need the college to tell you you are ready.  So while failing the exam is a pain, it is expensive, it is even embarassing it actually doesn’t matter.  The best FACEMs out there failed and now they are even better doctors than the rest of us.

You will pass when you don’t care about the belt…easy to say. But you need to believe it.

And lastly, when you do achieve your belt and go out there as a newly christened FACEM remember one last pearl of wisdom from Mr Miyagi.

“Licence never replaces eye, ear and brain”.

A FACEM doesn’t mean you stop learning, improving and making mistakes and learning from them.

Good luck to you all. Failure is not a thing it is a state of mind. If you conquer your fears you have caught a mighty big fly…

Like catching a fly with a chopstick you do that and you will “accomplish anything”.