Where does research appear in the fellowship exam?

Actually, it’s all the way through! It’s easy to spot in the written exam, but it is quite likely you will be asked about major trials in the vivas. As you explain your management in the Hot Cases you may be asked or volunteer (hint, hint this is a good idea) your rationale for your actions. Your knowledge of landmark research will help you here.

I am overwhelmed!! What do I have to know as a minimum?

For individual studies? The name or easily recognisable information, important methodological points (e.g. multicentre, double-blinded), the major results, the important inclusion criteria, exclusions, and the limitations of the study and (most importantly) how they would apply to your practice and decision making.

You do NOT need the specific dates (a general idea of how old the research is will do), an exhaustive list of authors, the journal edition, and the page numbers. You do NOT need a detailed exposition of the methodology. You need to memorize less than you will find on the abstract.

You will find in ICU research “clusters” as knowledge improves and becomes more refined. It is a good idea to have an awareness of the history and progression of some research areas. It gives you an insight into the nuances of intensive care and research in general.

I don’t believe you! The journal clubs and websites are so comprehensive and in depth!

Of course they are! They are overseen by people who love research and all power to them! They are interested in explaining the nuance and theory behind the research and as such they will be very precise and comprehensive.

The fellowship exam is broad and there is more of an emphasis on research translation than the purity of the science. The CICM fellowship exam is about a summarised grasp of research as it applies to the general intensive care population (SAQs and vivas) or a specific patient (hot cases).

What do you mean? Can you give me an example?

Exam questions about specific studies are more likely in the written paper than the vivas and hot cases.
For example, Q10 (b) the first sitting of 2022 about the PROSEVA trial.
   Outline the important findings, strengths and weaknesses of the PROSEVA trial.
                              (20% marks)

This question is straightforward and can be answered in bullet point format with headings as suggested by the stem.

Research study “clusters” require a more nuanced approach. Let’s look at Targeted Temperature Management in Out of Hospital Cardiac Arrest (OOHCA). This a topic that may be asked in the vivas or the hot cases. I have asked it many times to candidates both in the practice and in the real exam like this:
   Does cooling improve mortality and morbidity in OOHCA?
   What is your understanding of cooling in OOHCA?
   How would you temperature manage this patient? Provide justification for your answer.

A Possible Answer:

In the early 2000s, trials (including the multicentre HACA RCT) investigated hypothermia as a mechanism of reducing neurological injury in OOHCA. The HACA trial showed a benefit to therapeutic hypothermia HOWEVER the control arm was hyperthermic in many cases.

The subsequent international, multi-centre TTM trial showed no benefit from cooling to 33°C compared to 36°C– but the question of whether any cooling below normothermia was beneficial remained unsolved.

Enter TTM 2, a subsequent large international RCT which demonstrated no benefit between hypothermia (33°C) and normothermia (<37.8°C) with regards to mortality (primary outcome) or functional outcomes (secondary outcome).

It therefore appears that therapeutic hypothermia does not improve survival or aid recovery BUT avoiding hyperthermia may still be of benefit. Therefore, in my practice I do NOT cool patients with OOHCA to 33°C but I DO actively cool if temperature rises to over 37.5° with the aim of preventing hyperthermia.

In THIS patient the hot case stem tells me the patient had a respiratory arrest with pulseless electoral activity rather than a cardiac cause of their arrest. The literature relating specifically to hypoxic and non-shockable arrests is more mixed (e.g. HYPERION in non-shockable arrest). I would still actively prevent temperatures over 37.5°C in this patient as hyperthermia may decrease survival with a favourable neurological outcome. However, I would not aggressively cool to 33°C given the concern for hypothermia-associated harms (e.g. arrythmias) and uncertainty of benefit.

Tell me more about the “my practice” statement.

This is really the peak of all your training. It’s where you show that you are familiar with the literature, and you can apply it to many situations. Most candidates are so worried about the recitation of research facts they don’t realise how important this section is!
For a complete “my practice” answer, in any section of the exam, use this template:

• Explain why you WOULD
• Outline when you WOULDN’T
• Detail when you would START and when you would STOP the intervention
• Explain the rationale or pathophysiology behind it

What do I need to know about statistics?

This is a fellowship examination not a Masters in Biostatistics. Having said that there is a need to have a basic conceptual understanding of certain statistical principles to adequately critically appraise the literature and thus appropriately apply research to our patients.

The good news is that these statistical topics have largely been covered in prior questions. Statistics exam questions are inspired by common methodologies seen in major recent papers. Learn the definitions.

The “new” stats topics (whose buzz words include Bayesian and Adaptive Trial Design) are covered in our favourite websites (e.g. see here and here). The depth required is no more than the website explanations.

Keep your antennae waving in journal club. There is always someone who loves statistics even if the rest of the cohort doesn’t…

Any last tips for research as it applies to the fellowship exam?

Yes.

Attend journal club and get used to talking about research as it applies to patients. Include research snippets in your handovers to acquaint yourself with its inclusion in your thought processes.

Practice research SAQs and make some up yourself. Show your model answers to as many consultants as you can find!

Good luck!

References and Resources

1. Guérin C, Reignier J, Richard JC, et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368(23):2159-68. doi: 10.1056/NEJMoa1214103
2. Hypothermia after Cardiac Arrest Study Group (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346(8):549-56. doi: 10.1056/NEJMoa012689
3. Nielsen N, Wetterslev J, Cronberg T, et al. (2013) Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 369(23):2197-206. doi: 10.1056/NEJMoa1310519
4. Dankiewicz J, Cronberg T, Lilja G, et al (2021) Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med 384(24):2283-2294. doi: 10.1056/NEJMoa2100591
5. Lascarrou JB, Merdji H, Le Gouge A, et al (2019) Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med 2019 381(24):2327-2337. doi: 10.1056/NEJMoa1906661

Other Resources

The CICM Second Part Examination

Section Author

Dr Michaela Cartner
Michaela is an Intensivist who lives and works on the Gold Coast. She is an enthusiastic supporter of education and training. She loves to surf but is aware her limitations outweigh her skill set. She tries anyway.

Section Reviewer

Dr Emma Cooper
Emma is an intensive care senior registrar who is determined to believe there’s 36 hours in every day. She is passionate about expanding the natural habitat of gingers to include the Queensland outdoors, camera in hand, and supported by copious SP50.