JICS Volume 10, Number 1, January 2009 17
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
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.
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
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.
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
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
A Propofol does not accumulate significantly in renal failure
B Fentanyl has a longer context-sensitive half-life than
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
A Bronchodilation T
B Raised intracranial pressure T
C Apnoea F
D Hypotension F
Table 2 Typical type K question.
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
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
• A professional approach preserving patient dignity
• Integration of clinical information to form differential
• Ability in constructing a management plan and discussing
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
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.
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.
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
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-
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.
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.
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
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.
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
• 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
• 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.
1. COBATRICE: http:// www.cobatrice.org
2. Bersten A, Soni N, Oh TE. Oh’s Intensive Care Manual. Edinburgh:
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/
Steve Benington SpR Anaesthesia & Intensive Care, Royal
Brendan McGrath DICM EDIC, SpR Anaesthesia & Intensive
Care, Manchester Royal Infirmary