Special reports © The Intensive Care Society 2008
Volume 10, Number 1, January 2009 JICS16
The European Diplo...
JICS Volume 10, Number 1, January 2009 17
Special reports
Questions are divided equally into ‘Type A’ and ‘Type K’
Volume 10, Number 1, January 2009 JICS18
passing the part 1, providing the candidate has accrued
sufficient ICM experience ...
JICS Volume 10, Number 1, January 2009 19
sound knowledge of the evidence base in these areas will be
expected in the disc...
Volume 10, Number 1, January 2009 JICS20
an infectious disease unit, then a case concerning HIV-related
medicine is more l...
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The European Diploma in Intensive Care — EDIC


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The European Diploma in Intensive Care — EDIC

  1. 1. Special reports © The Intensive Care Society 2008 Volume 10, Number 1, January 2009 JICS16 Introduction The European Diploma in Intensive Care (EDIC) is a two part examination designed to test the candidate’s factual knowledge and its practical application to intensive care medicine (ICM). First sat in 1989 by 40 candidates, the exam is growing in popularity and last year was taken by over 300 examinees. In the UK, doctors applying for consultant posts in ICM are increasingly finding that possession of a dedicated qualification in the specialty is listed as “desirable” on the job specification. For doctors currently entering higher (step 2) ICM training, acquisition of either the EDIC or the UK Diploma in Intensive Care Medicine (DICM) is now seen as nearly mandatory. While the more academic DICM requires a 5,000 word dissertation, the EDIC does not, and is seen by many as a more relevant qualification which tests real life skills and knowledge, and which is internationally recognised. Although the EDIC has a relatively high pass rate (around 70%), it should be remembered that the candidates are motivated individuals who have chosen ICM training in addition to their base specialties, and who have a track record of passing demanding parent specialty professional examinations. The examination The EDIC is a two part examination administered by the Education and Training Committee of the European Society of Intensive Care Medicine (ESICM). The part 1 examination is a multiple choice (MCQ) paper designed to test the candidate’s knowledge across a broad range of areas of clinical and intensive care medicine. Candidates who successfully negotiate this can choose to sit part 2 of the examination after 24 months of ICM training (including complimentary specialty training). The part 2 exam is clinically based, and the candidate will be expected to travel to another intensive care unit and to be examined at the bedside. The syllabus is drawn from the European framework of Competency Based Training programme for Intensive Care in Europe (COBATRICE). This covers all aspects of intensive care medicine including applied basic science, resuscitation, diagnosis, disease management, professionalism and end of life care. The diploma is conferred by the ESICM once the candidate has passed both parts of the examination and has completed training in their parent specialty. Part 1 The EDIC Part 1 examination is a 100-question MCQ paper. It is a truly international exam; in the previous calendar year four sittings were held in Ede (Netherlands), Lisbon (Portugal), Kuala Lumpur (Malaysia) and Bern (Switzerland). Candidates must therefore be prepared to travel, and should give thought to securing accommodation and travel arrangements well in advance. Entry requirements Candidates must satisfy the minimum entry criteria: • Have full registration as a doctor • Currently be in a national training programme in a parent specialty • Be entered into a national training programme in ICM, or have completed at least 12 months’ ICM training, of which a maximum of six months may be in complimentary specialties. In addition, specialists with a substantive commitment to ICM are also eligible to sit the exam. The cost of the Part 1 exam in 2008 was €242 for non-ESICM members, with a 50% discount for members. Since the cost of membership of the ESICM for 1 year is €100, it makes sense to join in good time to qualify for the exam discount (be warned – membership may take some time to process, so join well in advance of the exam application deadline). Membership includes a subscription to Intensive Care Medicine, the journal of the ESICM which is a useful source of review articles. The European Diploma in Intensive Care — EDIC S Benington, B McGrath The European Diploma in Intensive Care (EDIC) is a two part examination set by the European Society of Intensive Care Medicine. It is becoming increasingly popular with UK trainees who see possession of a diploma as an advantage when applying for consultant posts. Part 1 is a multiple choice paper testing factual knowledge, while Part 2 tests clinical skills and judgement at the bedside and through oral examination. Candidates sitting the Part 2 examination will have completed at least 24 months’ ICM training (including complimentary specialties), and must convince the examiners that they would be capable of managing patients on a general intensive care unit to the standard expected of a consultant. Keywords: EDIC; education; diploma; intensive care medicine; examination
  2. 2. JICS Volume 10, Number 1, January 2009 17 Special reports Format Questions are divided equally into ‘Type A’ and ‘Type K’ questions. Type A questions consist of a stem with five possible answers, from which the candidate must select the most appropriate (example shown in Table 1). There is no negative marking; a correct answer in a type A question scores one point, a wrong answer nil. Type K questions consist of a stem followed by four related statements, each requiring a true or false response. For type K questions, all four responses must be correct to score a full mark, with a half mark being scored if three out of four responses are correct. A sample of type K question is shown in Table 2. Questions for the part 1 examination are based on the COBATRICE syllabus previously mentioned. While any area of this syllabus is ‘fair game,’ the exam is weighted towards certain areas such as cardiovascular, respiratory, sepsis and neuro-critical care. The vast majority of the questions are medical in nature, but a small number cover areas such as management, ethics, law and quality assurance. Preparation UK trainees with a background in anaesthesia will have already completed the FRCA or FFARCI examination prior to sitting the EDIC, and will be familiar with much of the content of the examination. Trainees from other disciplines will also have completed specialty examinations previously, and will be aware of the standard required. In addition to keeping up to date with the major topics (eg ARDS, sepsis, fluid management) and attending local educational meetings and events, much useful information can be gained from daily ICM experience – this is an exam with practical relevance with none of the esoteric questions typical of the MRCP examination. Candidates may choose to prepare by obtaining a copy of the COBATRICE syllabus (available to download from the ESICM website) and reading around its topics. Alternatively, the ESICM offers a distance learning course, Patient-Centred Acute Care Training (PACT). This consists of four learning modules divided into four themes: • clinical problems (eg arrhythmias) • organ-specific problems (eg hepatic failure) • skills and techniques (eg nutrition) • professionalism (eg ethics) While this covers the exam syllabus in comprehensive detail, it is a considerable expense (currently €700 for ESICM members). It may be worth exploring whether your institution wishes to purchase a subscription, enabling multiple candidates to benefit as well as acquiring a useful learning resource for all ICM trainees. Another means of preparation is attendance at the ESICM congress, an international meeting held in the autumn in a major European city. A selection of the content at this meeting is educational, and geared towards the EDIC examination, one sitting of which is held during congress. While this is not a ‘spoon-feeding’ session and attendance does not guarantee a pass, attending the congress gives the candidate an international meeting to add to their curriculum vitae, exam preparation and an attempt at the EDIC Part 1 all at the same time. Dedicated MCQ books are in short supply, although some anaesthesia MCQ books have a selection of ICM questions. Perhaps the simplest way of preparing is to read through an intensive care textbook, paying close attention to ‘examinable’ sections. Oh’s Intensive Care Manual and Critical Care Secrets are popular choices. Bear in mind that such reference books become out of date quickly; the examiners do not expect a detailed knowledge of the minutiae of ICM, but will expect the candidates to be up to date in topical areas such as the use of activated protein C for sepsis, and the role of therapeutic hypothermia. After taking the examination, results take one to two months to arrive by mail; results include a score as a percentage, the pass mark and a breakdown of the candidate’s performance in each question area. Candidates failing the part 1 EDIC examination are not allowed to re-sit the exam for 12 months, so proper preparation is essential, especially for those trainees who wish to gain the full diploma prior to applying for a consultant post. The pass mark is around 56%, with about 70% of candidates passing in any one sitting. Part 2 Entry requirements The minimum entry criteria for the part 2 examination are: • A pass in the part 1 examination • Completion of at least 24 months’ ICM training, of which a maximum of six months may be in complimentary specialties. In practice, this means that UK trainees may sit the examination towards the end of their step 2 training. The part 2 examination can be taken up to four years after Regarding the properties of sedative medication used on the intensive care unit which of the following statements is FALSE? A Propofol does not accumulate significantly in renal failure B Fentanyl has a longer context-sensitive half-life than remifentanil C Midazolam exhibits metabolism-dependent kinetics X D Clonidine is an alpha-2 agonist E Ketamine raises intracranial pressure Table 1 Typical type A question. The following are expected physiological effects of a bolus of ketamine A Bronchodilation T B Raised intracranial pressure T C Apnoea F D Hypotension F Table 2 Typical type K question.
  3. 3. Volume 10, Number 1, January 2009 JICS18 passing the part 1, providing the candidate has accrued sufficient ICM experience as stipulated above. Fortunately, there are many more centres examining candidates for the part 2 than part 1, and the candidate is unlikely to have to cross international borders. However, the part 2 is a much more labour-intensive process for the examiners, and most centres can only accommodate a few candidates for a particular sitting. This means that booking well in advance is necessary. Two attempts are allowed initially; if a candidate has not succeeded at the second attempt, a further two attempts are allowed 12 months later. Format The part 2 examination consists of a clinical and an oral component. The clinical examination takes place at the bedside, lasts 60-90 minutes and consists of one long case and two or three short cases. The candidate will then be examined orally for 30-40 minutes on clinical material, testing aspects of ICM not explored in the long and short cases. The clinical component During both long and short cases the candidate will be expected to demonstrate: • Ability in eliciting clinical information which is accurate and comprehensive • A professional approach preserving patient dignity • Integration of clinical information to form differential diagnoses • Ability in constructing a management plan and discussing therapeutic options. During the long case the candidate has 30-40 minutes to familiarise themselves with a patient on the ICU of the examining centre. During this time they will have access to the patient’s case notes, charts and bedside monitoring, and will also have the opportunity to examine the patient and review blood tests, imaging and other investigations. The aim is to simulate as closely as possible the process of real life assessment of a genuine ICU patient. The candidate will be asked to summarise the clinical course of the patient before being questioned on specific areas of management. A sample case with associated questions is shown in Figure 1. In addition to the long case, two or three bedside short cases will be examined. These may focus on a clinical sign (eg a heart murmur), a procedure (eg chest drain insertion) or a clinical examination (eg brainstem death testing). Each short case will take around 15 minutes. A selection of recent candidates’ short cases is show in Table 3. The oral component This will take place in a quiet environment away from the bedside, and may explore themes derived from the clinical component or new topics. It may follow on from the short cases or be scheduled at a separate time on the same day. Visual material such as chest X-rays, ECGs, blood tests or photographs may be provided. Abbreviated case histories may also be used to explore areas not readily tested in the clinical component, such as ethical dilemmas. A sample of recent questions is provided in Table 4. The role of the candidate is to convince the examiners that he/she would be competent as the ICM physician in charge of these patients’ care. As with all intensive care patients, there are certain themes which are recurrent, for example ventilation strategies, sepsis care bundles, therapeutic hypothermia, and a Special reports Case summary The exam took place on a busy, working ICU. My centre was Birmingham City Hospital and local consultants were the examiners. My long case patient was about to be extubated and was rolled and washed during my exam time! The exam was fairly relaxed and with very clinically based topics and practical questions such as ‘what would you do now...?’ I was taken to the bedside and given 30 minutes (but could have had 40 if required). The patient’s own medical notes were available in full including that day’s entry. Diagnosis and treatment to date were clearly documented, nothing was hidden. X-rays and CT scans were available to view. Drug and fluid balance charts were also available. An ICU nurse present was very helpful. The patient was an intubated, ventilated, 64 year-old man who had been on the ICU for seven days. He had initially been investigated for painless jaundice, and CT abdomen had shown pancreatic carcinoma. Following a failed ERCP, he had presented con- fused and hypotensive to the emergency department. Biochemistry showed acute hepatic and renal failure with an INR of 10. A percutaneous biliary drain had been inserted. Klebsiella had been isolated from biliary fluid, blood and urine cultures. Chest X-ray was consistent with ARDS. Continuous veno-venous haemofiltration was in progress. Questions and topics discussed Summarise the case, and outline the underlying problem Discussion of circulatory support, pattern of LFTs, modes of renal replacement therapy What would your initial choice of antimicrobial therapy be? Is he ready to wean? Would you readmit this man? Who makes that decision? Back to initial presentation in the emergency department: how would you resuscitate him? Fluid choices, discussion of normal saline and hyperchloraemic acidosis Pros and cons of central venous line with severe coagulopathy Figure 1 One candidate’s long case.
  4. 4. JICS Volume 10, Number 1, January 2009 19 sound knowledge of the evidence base in these areas will be expected in the discussion. The candidate receives a mark for both the clinical and oral parts of the examination of either Fail, Bare Fail, Pass or Excellent, based on the criteria outlined above. A Pass or better in each component confers a pass overall, and a Fail in any component ensures failure overall. A Bare Fail in one component may be compensated for by a good Pass or Excellent grade in the other component at the discretion of the examiners. A candidate who has clearly done well or very poorly may be notified of the outcome at the end of the examination; more borderline cases will require a period of discussion by the examiners and they will receive their results by mail at a later date. Preparation Candidates sitting the part 2 examination will have completed 24 months of intensive care training and will be close to applying for consultant posts; a sound level of knowledge and judgement is therefore expected. Much of the required factual knowledge will have been gained through preparation for the part 1, but more importantly the candidate will have a bank of practical ICM experience on which to draw. Those lucky enough to work alongside EDIC examiners should seize the opportunity for practice whenever it occurs. Most departments have experienced consultants willing to provide exam practice, and word soon gets around regarding who is ‘good value’ for this sort of thing. It is useful to pair up with a fellow trainee who plans to sit the exam, each testing the other. As important as factual knowledge is the ability to communicate it effectively and this improves with rehearsal. Most ICU patients can serve as the focus for either a long or short case; some may have an unusual diagnosis or clinical sign, but even the ‘bread and butter’ sick patient with sepsis and ARDS is a rich source of material: what is the evidence for using activated protein C in such patients? What strategies can be used to oxygenate the patient? Which are evidence-based? What are the issues to be considered when contemplating withdrawal of treatment? Is this patient a candidate for non- heart beating organ donation? In addition to hands-on practice, it is crucial to stay up to date on major topics. The major ICM journals such as Intensive Care Medicine, Critical Care Medicine, Journal of the Intensive Care Society and the online journal Critical Care often carry good review articles of the major topics. It is useful to sign up to receive the tables of contents of these journals by e-mail to avoid missing something recent and topical. It may be worth writing a list of examinable ‘hot topics’ and then seeking out recent reviews and classic papers on these subjects. It is a fair bet that steroids in sepsis, therapeutic hypothermia, and management of the patient with ARDS might all come up, and it would be unwise to be under-prepared in these areas. While review articles are a useful means of keeping up to date with the hot topics, a good textbook is also a must. Areas such as hepatic failure in critical care lend themselves less well to evidence-based review articles, but the basic management of such conditions changes little from one year to the next. It would be sensible to find out in advance whether the examining centre has any specialist interests: if the hospital has Special reports Acute severe asthma I was shown a patient being ventilated with acute severe asthma. Questions were based on the emergency management of asthma including the British Thoracic Society guidelines, and the problems that might be encountered in mechanically ventilating such patients. I was also asked whether I would insist on an arterial blood gas sample on a distressed asthmatic patient in the emer- gency department. Metabolic encephalopathy I was asked to perform a neurological examination on an elderly lady sedated with propofol. She was hypotonic with bilateral upgo- ing plantars and unreactive pupils. I was asked for the differential diagnosis of this presentation, and was subsequently told that she had a plasma sodium of 108 mmol/L. I was asked about the initial management, and then how to determine the cause of hypona- traemia in this patient. A discussion of correction of hypona- traemia and complications then followed. Pulmonary oedema I was asked to perform a cardiovascular examination on a lady of 60 who was uncooperative and receiving CPAP via a helmet. Very little was audible on examination due to ambient noise, but she had bibasal crackles and ankle oedema suggesting pulmonary oedema. I was questioned about the causes and acute manage- ment of pulmonary oedema, the relevance of any scars and the role of the cardiologist in such patients. The role and timing of secondary therapies including ACE inhibitors and beta-blockers was then discussed. Table 3 Typical short case topics. Care bundles What is a care bundle? Can you name some? Tell me about the elements of the sepsis/ventilator care bundles. Tell me about the indications for activated protein C in sepsis. Hypoxic brain injury How would you manage a patient with hypoxic brain injury? What is the role of therapeutic hypothermia? What treatable conditions should you exclude in a comatose patient? What evidence is there to guide prognostication in such patients? How would you proceed with a patient who hasn’t regained con- sciousness after several days? Pneumocystis jirovecii pneumonia Tell me about this chest X-ray from a young man with a short his- tory of respiratory failure. What is the differential diagnosis? What are the features of Pneumocystis carinii pneumonia? How would you confirm the diagnosis? What are the management options? Discuss the ethics of HIV testing in the ventilated, sedated patient. Table 4 Typical oral examination topics.
  5. 5. Volume 10, Number 1, January 2009 JICS20 an infectious disease unit, then a case concerning HIV-related medicine is more likely; if there is a large neurology department, a case of myasthenia gravis is a distinct possibility. Ultimately, the candidate must be prepared to deal with any topic thrown at them, and be able to convince the examiners that they would be a worthy colleague in their own department. Top tips • Review articles from the major journals are a good source of information. Both the EDIC and the journal Intensive Care Medicine are affiliated to the ESICM • Practice makes perfect when preparing for the part 2 examination • While a limitless number of diseases may precipitate intensive care admission, there is a finite list of ICU-related problems that patients display once there • Treat the clinical exam as if you were on the daily ward round, presenting your long case and proposing and justifying your management. Clinical signs and common abnormalities in results should be interpreted just as you do on a daily basis. Further reading 1. COBATRICE: http:// www.cobatrice.org 2. Bersten A, Soni N, Oh TE. Oh’s Intensive Care Manual. Edinburgh: Butterworth-Heinemann. 2003. 3. Parsons PE, Wiener-Kronish JP. Critical Care Secrets 3rd Edition. London: Elsevier Health Sciences. 2003. 4. DICM webpage: http://www.dicm.co.uk/papers.htm 5. ESICM website: http://www.esicm.org 6. ICS website: http://www.ics.ac.uk/ Special reports Steve Benington SpR Anaesthesia & Intensive Care, Royal Preston Hospital stevebenington@hotmail.com Brendan McGrath DICM EDIC, SpR Anaesthesia & Intensive Care, Manchester Royal Infirmary