The Cognitive Matrix
by Dr Zaahid Pandie

hi everybody. Welcome to the first post on this blog. So much has been written and suggested about how to pass the ACEM Fellowship Exam. This first post is really a snapshot of what to do with any topic you are studying for the exam. Having had first hand knowledge of how questions are set for the SAQ exam, this is my ‘Thought Matrix’ for most topics in the syllabus.

Let’s start with any generic topic – eg heart failure. Use the matrix below to summarize the topic for the exam:

Assessment Questions

Consider what the examiner is likely to ask on this issue. Acute Pulmonary Oedema is probably the key type of question.

Classification systems for heart failure
Include Framingham, NYHC 1-4, Killip classes for left heart failure, besides the issues of preserved and non preserved left systolic function.

UpToDate has the best article on this particular issue for heart failure. There is also the recently AHA guideline on heart failure.

Precipitants are a common source of question in the exam eg infection, ischemia, lack of compliance or excess fluid or salt intake are all common precipitants of acute heart failure.

Aetiology is a vast separate issue with causes being protean.

Clinical Features
Being able to succinctly list the symptoms and signs of heart failure that are sensitive or specific is important. This is usually an area of the exam very poorly executed by candidates due to a lack of adequate on the floor clinical teaching.

Investigations likely to be produced for this question include CXR, Troponin, ECG or other cardiac markers such as BNP and echo analysis. Detailed knowledge of these sensitivities vs the sensitivities of the clinical signs is important.

Obviously this will impact the way the topic is studied and also alter the depth of knowledge required.

Management Questions

The management matrix above is a generic outline for stating very specific information based on the assessment of the problem provided. Management of heart failure with poor left ejection fraction utilizing inotropes and possibly even LV assist or intra-aortic balloon bump measures is very different from predominantly right heart failure with preserved left ventricular function where the mainstay is NIV, inodilators and management of underlying causes such as ischemia.

Use a cognitive matrix to strategize and structure your study of the exam topics