2019 Fellowship examination report

The Fellowship examination is a fundamental part of the pain medicine training program, leading to
the award of Fellowship of the Faculty of Pain Medicine. The examination consists of written and oral
sections and covers the theory and practice of pain medicine. The curriculum guides the range of
content which may be assessed.

The 2019 Fellowship examination was held on 3 October and 1 December at regional centres and
the AMC National Test Centre in Melbourne.

The purpose of the examination report is to provide candidates and Supervisors of Training with
exam-related information to assist with the preparations of studies and to encourage discussions
between mentors and candidates so that candidates may prepare optimally for their future
examinations.

The information provided are current and evidence-based and, may be subject to change in the
future.

1. Fellowship Examination: Overall Pass Rate 68%

Written Section: Pass rate: 73%

Forty candidates sat the written examination on 3 October, of which, twenty-nine were successful.
Candidates were required to answer ten compulsory questions of equal mark value.

Where there was more than one section to the question, all sections were to be answered.
Questions included clinical scenarios, data interpretation, and discussion and analysis of pain
topics such as spinal procedures, substance abuse, fear and anxiety, acute post-surgical pain and
cancer pain.

All questions were marked out of 10 and candidates were required to:
- Answer the question.
- Plan the answer in a logical fashion and demonstrate an organised approach.
- Give succinct answers and avoid repetition.
- Use headings and dot points if asked to list or discuss briefly.
- Write legibly – if the examiners could not read the answers, they could not award marks.
- Give definitions of specialist terms (e.g. neuropathic pain, placebo response or

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 breakthrough analgesia). Examiners were unable to assume understanding or meaning
of a particular term without clear definition - similarly for abbreviations.
- Start answers with “I would do…” if asked to “outline your approach to…”

The Examination Committee decided to remove question 10, following review by the Australian
Council of Educational Research and after discussion by the Examination Committee. The
pass mark was 5/10 for each question and 45/90 for the examination.

Question 1 PASS RATE 95 %

Discuss how the history and culture of indigenous peoples impacts on their pain experience,
and the potential difficulties in providing multidisciplinary pain management.

This question was passed by most candidates, but few candidates scored highly. Those who
considered issues around the negative impact of colonisation on the socioeconomic and poorer health
status of indigenous populations, performed better. Candidates could have achieved higher marks by
discussing the need for culturally appropriate pain assessment tools and questionnaires, pain
education material, and pain management programs.

Question 2 PASS RATE 95 %

You are asked to consult a 19-year-old primigravida at 25 weeks gestation in the orthopaedic
ward. She presented with a displaced right tibial fracture and is day 2 following an open
reduction and internal fixation. Prior to admission, she was using illicit opioids at least daily.
She is crying, distressed, and complaining of severe pain in her right lower leg. On review of
her charts, she has a low grade fever, tachycardia, hypertension, and is noted to be diaphoretic.
Discuss the principles underlying acute pain management for this patient, including factors
that need to be considered when she is discharged.

All candidates seem to have understood the question well. Quite a few candidates did not mention a
thorough pain assessment in their answers.
Most candidates achieved a pass mark in this question and a number performed extremely well
considering that this may be an area that is not main-stream in many hospitals. This question was
designed to assess candidates’ understanding of the issues around patients presenting with acute
pain and opioid dependency, effects of treatment on both the mother experiencing acute pain and her
foetus and, issues around opioid stewardship and discharge.

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Question 3 PASS RATE 85 %

Compare and contrast the clinical features of somatic and visceral pain.

This question asked the candidates to compare and contrast the clinical features of somatic and
visceral pain. This question has been asked in a similar manner in a previous paper and is a core part of
the pain training syllabus.
Overall the question was answered in a structured manner with the better answers comparing and
contrasting the clinical features in a tabulated form. Some answers started by defining each of somatic and
visceral pain and then comparing and contrasting the two. Many answers had the answer in two tables
with the features listed and then compared and contrasted.

Question 4 PASS RATE 53 %

Opioids are commonly used in the treatment of pain.

Outline the evidence base for their efficacy in chronic non-cancer pain.
Discuss the long term adverse effects of opioid use.
List the clinical features that predispose to an increased risk of opioid abuse.

For such an important clinical topic, this answers to this question were extremely disappointing as
reflected by the lower than expected pass mark. An excellent knowledge of opioid pharmacology is a
core expectation for specialist pain medicine physicians. This question has also previously appeared
in different guises over the years because the examiners recognise its essential nature.
In general candidates did not demonstrate the level of knowledge in this area, that is expected of a
specialist pain medicine physician.
Whilst it was reassuring that many candidates were able to reference the FPM guidelines on opioid
use in chronic non-cancer pain, just quoting these was deemed insufficient. At this level it is expected
that candidates can produce an evidence based argument for their stance.
Long term consequences of opioid therapy including neurocognitive, motivational, dependence and
tolerance, endocrinological including on bone and reproductive health are all areas that could have
been explored.
Most candidates did not discuss aberrant drug-taking behaviours that predispose to an increased risk
of opioid abuse.

Question 5 PASS RATE 70 %

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Discuss the principles of assessment and management of an acute episode of low back pain
in an 85-year-old patient with dementia.

It is important for candidates to recognise that this question asked about “assessment and
management” in an episode of acute low back pain. This implies that the pain was not chronic in
nature. Part of the assessment of low back pain in a patient with dementia involves trying to gather a
collateral history as the patient is unlikely to be a good historian. Ensuring that causes other than
spinal pain for back pain in a patient in this age group e.g. ruptured aortic aneurysm, renal calculi, UTI,
metastatic cancer etc. are considered as part of the differential diagnosis was important for candidates
to score well.
The second part of the question requires candidates to articulate their investigations and management
plan. Very few candidates discussed MSU as part of their investigations and responses lacked detail
in management plans.

Question 6 PASS RATE 60 %

Discuss the evidence for the efficacy of cannibinoids in the management of pain and other
symptoms in palliative care.

This question is taken almost verbatim from the learning outcomes of the curriculum - 3.6.24.
Candidates generally concentrated on multiple sclerosis (MS) and seizure disorders but the question
specifically asked about “cannabinoids in palliative care”. Most patients with MS live long and
productive lives. References to chronic pain and Dravet’s syndrome where the evidence for the use
of cannabinoids remains limited, was not awarded marks.
It was expected that a discussion would include patients with chemotherapy induced nausea.

Question 7 PASS RATE 80 %

A 55-year-old patient presents with left hemi-facial pain of 4 months duration.

1. List the differential diagnoses.
2. Describe the spectrum of temporo-mandibular joint dysfunction.
3. Discuss the evidence base behind the treatments for temporo-mandibular joint disease.

Overall the question was answered reasonably well. Part 1 required a list of differential diagnoses that
account for chronic unilateral hemi-facial pain. Most candidates had a good knowledge of these. The
second part of the question on the spectrum of TMJ disorder, lacked detail in many responses. A more
comprehensive answer to this section would also include comments on areas including the incidence,

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aetiology, pathophysiology, clinical assessment and investigations that are utilised in the assessment
of temporomandibular joint dysfunction. The final section required comments on the current evidence
with regard to various treatments for TMJ disease. Many candidates listed treatment options but there
was a lack of specific reference to evidence. The most comprehensive answers also included a
discussion about conservative treatments and the role of cognitive behavioural therapy.

Question 8 PASS RATE 58 %

Discuss the diagnosis of somatic symptom disorder, SSD (DSM-V), and its relevance in pain
medicine.

This question was poorly answered with a pass mark that was just over 50% and few candidates
scoring high marks. Candidates were expected to be able to able to define the diagnosis of somatic
symptom disorder as described in DSM-V. They were expected to describe its relevance to pain
medicine with specific examples relevant to pain medicine such as chronic widespread
pain/fibromyalgia and complex regional pain syndrome. The good candidates also discussed fictitious
disorder as well as how SSD was an improvement on the category of the former somatoform disorder.

Question 9 PASS RTAE 65 %

Describe the limitations of evidence-based medicine in the context of the practice of pain
medicine.

This was a simple introductory question however some definitions were required, followed by a critical
analysis of evidence based medicine EBM in pain medicine; this was lacking in most answers and
where attempted, levels of evidence were often incorrectly described.
Most candidates noted pain presentations to be complex with confounding psycho-social aspects
making measurement challenging but, they did not extrapolate to potential variations in response or
outcomes, let alone non normative distribution of data. Many candidates acknowledged bias as a
limitation specifically with pharmaceutical company funding or publication bias. There was very limited
commentary on analysis of statistical methods.
Candidates frequently used examples with the MINT trial being the most commonly quoted, viewing
its outcome as not representative of clinical practice suggesting that candidates did not accept the
outcome of this randomised control trial.

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Question 10 PASS RATE NA

This question was removed following review by ACER and after discussion by the examination
committee.

______________________________

The successful candidates in the written section were invited to the oral section which was held at
the Australian Medical Council National Test Centre, Melbourne on December 1, 2019.

Oral Examination Overall pass rate: 93%

In accordance with the Faculty of Pain Medicine Training Handbook, in the course of the
examination day, each candidate was required to undertake 8 viva voce stations. The viva voce
consists of four objective structured clinical examination (OSCE) stations (10 minutes each) and
four structured viva voce examination (SVVE) stations (15 minutes each).

Each viva were carefully scripted to assess specific educational objectives and attracted equal
marks. Each viva were carefully scripted to assess specific educational objectives and attracted
equal marks. Actors and examiner role players were utilised in some stations.

The following qualities were assessed:

 Clinical judgement

 The application of principles of acceptable and safe pain medicine practice

 Prioritisation

 Interpretation of complex clinical situations

 An ability to make decisions based on changing clinical situations

 Anticipation of clinical actions and their sequelae

 Effective communication.

OBSERVED STRUCTURED CLINICAL EXAMINATION (OSCE PASS RATE 90%

This section consisted of four highly structured stations which were carefully scripted to assess specific
educational objectives with a focus on clinical skills. An introductory case scenario was used to
introduce the topic area and to enable the candidate to orientate to the particular task. Simulated
patients were utilised in some stations.
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OSCE 1 Pass rate 68 %

You have started working in a small pain management practice as the second pain medicine
specialist.
Recently, you were appointed as the supervisor of training. One of the members of the
multidisciplinary team (the physiotherapist-Sarah) has voiced concerns to you about the
current Pain Medicine trainee Dr Smith. These concerns relate to inappropriate sexual
behaviour of the trainee towards them.
They allege the following: That the trainee has asked them out dates on numerous occasions.
That Dr Smith was clearly told “no” by the physiotherapist. Despite this, Dr Smith continued to
pursue them. When the trainee and the physiotherapist are alone together, the trainee
comments on their appearance and makes remarks and jokes with sexual overtones. Sarah
also feels as though the trainee tries to impinge on their personal space such as knowingly
blocking their access to a room so they cannot enter without physical contact. Sarah has made
it clear to you that they feel very uncomfortable around the trainee and unsafe with them when
left alone.
The alleged behaviour has been viewed by another member of the team.
You are about to have a meeting with Dr Smith. How are you going to demonstrate your
management of this situation?

This was a communication viva with an examiner acting as Dr Smith. The theme was unprofessional
behaviour.
Marks were awarded for the candidate framing or setting the agenda. It was anticipated that an
objective and empathetic discussion would then take place. Enquiring after the trainees point of view
and wellbeing is one important aspect. It was important that the gravity and implications of the
behaviour were presented to the trainee. Zero tolerance for sexual harassment was expected. Some
but not all candidates outlined the behaviour change that was expected of the trainee. It was also
important that the issue was escalated to the Head of Department because the allegation related to
workplace and training issues.

OSCE 2 Pass rate 55 %

Male aged 32 with a 3-year history of pain and disability in his non-dominant left hand that was
crushed in a motor cross accident during which he sustained a fracture at the 5 th MCP joint. No
surgery was performed. At the time he was an apprentice chef but had to give up that ambition
due to his inability to lift heavy pots. He also had to move back home to live with his parents.
He smokes marijuana to relieve the chronic persistent discomfort that principally affects the
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distal ulnar nerve distribution with pins and needles perceived in the left wrist, with occasional
shooting pains into the 4th and 5th digits of the left hand.

Please perform a pain orientated sensory examination of the limb and comment as you do.

Candidates were expected to show sensibility to patient checking for allodynia verbally before starting,
show safety, hygiene demonstrate a smooth examination flow and presentation.

Objectives
 Demonstrate the principles of sensory testing with comparison to the unaffected limb
 Ability to accurately define neuropathic descriptors

OSCE 3 Pass rate 63 %

Sam is a 52 year old divorced parent of twin teenage girls aged 17yrs. One of the twins, Lisa
has chronic widespread musculoskeletal pain. Sam has made an appointment to come and see
you, without Lisa, to find out if you can help.

This station was generally well managed and requires ability to communicate, collaborate and
recognise and manage physical and psychological risk.

OSCE 4 Pass rate 50 %

You will see 3 short videos of patients with gait abnormalities. After each video you will be asked
to describe the features of the gait pattern and there will be some further questions.

Structured Viva Voce Examination (SVVE) PASS RATE (97%)

This section consisted of four stations which were carefully scripted to assess specific educational
objectives with a focus on clinical reasoning and dilemmas in pain medicine. An introductory case
scenario was used to introduce the topic area and to enable the candidate to orientate to the situation.

SVVE 1 Pass rate 70 %

You are asked to see a 52 year old woman who presents with a 2 week history of progressive
headache in the Emergency Department on a Friday afternoon. She has had some headaches
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in the past for years labelled migraine headaches but feels her headaches have changed in the
last few weeks. Her general health is good but she has had a “SCC” removed from her leg 5
years ago, is a smoker and is on Rivaroxaban for a deep vein thrombosis.

This scenario was well answered by most candidates who were able to:
 Take a detailed headache history to exclude life threatening causes and provide a differential
diagnosis.
 Discuss physical findings on examination that may assist in the assessment of headache.
 Discuss appropriate investigations and their urgency for headache assessment.
 Discuss evidence base for non-drug interventions in headache.

SVVE 2 Pass rate 48 %

You will be introduced to 4 brief individual patient scenarios, one at a time.

You will then be asked to review the investigations of each of the 4 separate patients and
comment on the findings and/or impact on their pain management.

SVVE 3 Pass rate 73 %

You are rung by a surgical colleague regarding a 45 yr woman who is reporting severe post-
operative pain immediately following a laparoscopic cholecystectomy.

They note she takes fentanyl 25 mcg/hr via a transdermal patch for non-specific low back pain,
managed by her GP in the community.

The surgical team is planning for discharge within 24 hrs as per their protocol.

This acute pain question tested knowledge around opioid tolerance in the acute postoperative period
and safe practice of communication with a surgical colleague and patient in pain.

SVVE 4 Pass rate 65 %

As a pain consultant covering a hospital acute pain round you are called by the oncology team.
They ask you to see a 38 year old male with severe abdominal pain on the background of
pancreatic cancer. They are considering the provision of a third line chemotherapy agent but
in the meantime would like your review of this man’s pain. His current medication list for
analgesia is Methadone 50mg tds, Endone 20mg prn and paracetamol 1g tds.

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THE BARBARA WALKER PRIZE / CERTIFICATES OF MERIT

Dr Dana Weber (WA) reached the required level of excellence to receive the Barbara Walker Prize of
Excellence. Certificates of Merit were awarded to Dr Tze Chow Chow (VIC), Dr Gloria Seah (VIC) and
Dr Ramsey Jabbour (NSW).

Dr Kieran Davis
Chair, FPM Examination Committee
September 2020

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